La mastectomía ahorradora de piel como alternativa a la mastectomía estándar en el cáncer de mama

Postoperative Complications Following Prepectoral Versus Partial Subpectoral Implant-Based Breast Reconstruction Using ADM: A Systematic Review and Meta-analysis

BACKGROUND

There is a paucity of evidence comparing the safety of prepectoral and partial subpectoral implant-based breast reconstruction using acellular dermal matrices (ADM). We performed a meta-analysis to evaluate the postoperative complications of the two approaches.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The rates of the complications were, respectively, pooled, and relative risk (RR) was estimated with 95% confidence intervals (CIs) to compare the incidence between the two cohorts.

RESULTS

Ten articles reporting on 2667 breast reconstructions were eligible. The hematoma rate was lower in the prepectoral group (RR  =  0.590, 95% CI 0.351-0.992). No significant difference was observed in terms of seroma (RR = 1.079, 95% CI 0.489-2.381), skin flap necrosis (RR = 0.936, 95% CI 0.587-1.493), infection (RR = 0.985, 95% CI 0.706-1.375), tissue expander/implant explantation (RR  =  0.741, 95% CI 0.506-1.085), wound dehiscence (RR = 1.272, 95% CI 0.605-2.673), capsular contracture (RR = 0.939, 95% CI 0.678-1.300) and rippling (RR = 2.485, 95% CI 0.986-6.261). The RR of animation deformity for the prepectoral group compared with the subpectoral group was 0.040 (95% CI, 0.002-0.853).

CONCLUSIONS

This systematic review suggested that with appropriate patient selection, prepectoral breast reconstruction could avoid animation deformity without incurring higher risk of early wound complications, capsular contracture or rippling than partial subpectoral breast reconstruction. Plastic surgeons should complete a comprehensive assessment of the patients before choosing appropriate surgical approaches in clinical practice.

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 .

Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes

BACKGROUND

The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking.

METHODS

Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors.

RESULTS

Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis.

CONCLUSIONS

Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Should Obesity Be Considered a Contraindication for Prepectoral Breast Reconstruction?

BACKGROUND

Prepectoral implant-based reconstruction reemerged as a viable approach following recent advances in reconstructive techniques and technology. To achieve successful outcomes, careful patient selection is critical. Obesity increases the risk of complications and has been suggested as a relative contraindication for prepectoral breast reconstruction.

METHODS

Retrospective chart review of patients who underwent immediate two-stage implant-based reconstruction at the authors' institution was performed. Only women having a body mass index of 30 kg/m or greater were included. Patient demographics, operative details, and surgical outcomes of prepectoral and subpectoral reconstruction were compared.

RESULTS

One hundred ten patients (189 breasts) who underwent prepectoral and 83 (147 breasts) who underwent subpectoral reconstruction were included. Complications were comparable between the two groups. Twelve devices (6.4 percent), including implants and tissue expanders, required explantation in the prepectoral group, and 12 devices (8.2 percent) required explantation in the subpectoral group (p =0.522). Final implant-based reconstruction was achieved in 180 breasts (95.2 percent) in the prepectoral group and 141 breasts (95.9 percent) in the subpectoral group. Regardless of type of reconstruction (prepectoral or subpectoral), for each point increase in body mass index, the odds of complications and device explantation increased by 3.4 percent and 8.6 percent, respectively; and the optimal cutoff to predict higher complications and explantation rates was a body mass index of 34.8 kg/m and 34.1 kg/m, respectively.

CONCLUSIONS

Obesity increases complications and failure rates in a positive correlation; however, complications and final reconstruction rates are comparable between the prepectoral and subpectoral groups. The authors believe that obesity should not be a contraindication for prepectoral breast reconstruction but that care should be taken in patients with a body mass index above 35 kg/m.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction

BACKGROUND AND AIM

Tissue expander-based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander placement to the traditional submuscular placement and describes our early experience with the expander insertion plane-choosing algorithm.

METHODS

A retrospective study of patients who underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was conducted. All expander insertion planes were chosen using the same algorithm. Expansion, pain, and complications were compared between two groups.

RESULTS

The study included 88 patients (158 expanders; 50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion ratio (p < 0.001), high first postoperative expansion ratio (p < 0.001), shorter duration of expansion (p = 0.02), less number of expansion visits (p = 0.002), and less average pain during admission (p = 0.004). Significant differences in the intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p = 0.005 and 0.01, respectively). Complications during expansion and after second-stage autologous flap reconstruction were comparable between two groups.

CONCLUSION

The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits, and less pain. With the expander insertion plane-choosing algorithm, subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. Further studies can be performed due to the lack of long-term complications following second-stage implant reconstruction in the subcutaneous approach.

[Nipple sparing mastectomy: an update]

In order to decrease the psychological impact and the mutilating feeling of surgical treatments of the breast cancer when the mastectomy is indicated, authors described and propose the nipple sparing mastectomy (NSM). The only opposable criticism would be the increase of recurrence rate. The study of the recent literature allows us to make a inventory of fixtures concerning this evolution of the surgical practices whether on a technical, oncological, plastic or psychological plan. This technique is not validated in France and adjuvent therapies as the radiotherapy of the nipple are not validated yet. It seems that the NSM is a safe practice from the carcinologic point of view, while having a positive psychological impact in terms of disease and treatment acceptance. The technique seems possible after an information and selection of the patients and with a respect for technical rules (frozen section, peroperative evaluation of the nipple vitality).

["Scarless" surgery in the treatment of breast cancer]

So-called "scarless" surgery in the treatment of breast cancer consists of a group of procedures with a double aim: local control of the oncological process and maintaining the body image of the woman by making incisions that will not be visible. This article describes four approach routes for scarless surgery (periareolar, axillary, submammary, lateral chest) in different contexts of the oncological breast disease. The application of these incisions in the conservative treatment of breast cancer requires making a wide subcutaneous dissection over the tumour location, and a local reconstruction with adjacent breast tissue, so as not to deform the breast contour, as well as moving the nipple with its areola, thus avoiding the surgical modification of the other breast to maintain symmetry between both. We describe the use of hidden incisions to perform mastectomies that try to conserve as much skin as possible, together with the nipple, as well the dissection, with the aid of an endoscope of the latissimus dorsi muscle, in the immediate breast reconstruction.