ESPRAS Survey on Breast Reconstruction in Europe

Medicolegal and insurance issues regarding BRCA1 and BRCA2 gene tests in high income countries

Hereditary breast and ovarian cancer syndrome is an autosomal dominant cancer susceptibility syndrome mainly due to variants in BRCA1 or BRCA2 genes. Patients presenting with BRCA1 or BRCA2 gene mutations have a lifetime risk of developing breast or ovarian cancer (80% and 40%, respectively). Genetic testing to explore the predisposition to develop cancer represents a pivotal factor in such cases, and this review wants to explore the main implications in terms of medicolegal liability and insurance issues. Medicolegal issues related to these diagnostic processes include: (a) failure to recommend the test; (b) failure to properly interpret the test; (c) failure to correctly translate results into clinical practice; (d) lack of informed consent; and (e) failure to refer patients to specialized genetic counseling. Such errors may lead to compensation since the legal burden inherent in the efficacy of prophylactic interventions is a proof that requires the so-called 'preponderance of the evidence'. Concerning insurance issues, the carriers of such alleles without cancer are healthy because the genetic predisposition is not a disease per se but represents a (relevant) health risk. However, disclosure of these conditions can be impelled by insurers. It can lead to so-called 'genetic discrimination' because insurance companies might use genetic information to limit insurance options or increase their costs. Many private and public healthcare funders do not cover risk reducing surgeries, even when recommended as part of a risk reduction management plan for BRCA gene mutation carriers. Here, positions on these matters from different high income countries are discussed, stressing the importance of a common supranational or international regulatory framework to reach a trade-off between the economic interests of insurers and the rights of carriers not to disclose extremely sensitive information.

Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction

BACKGROUND

There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies.

METHODS

Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting.

RESULTS AND CONCLUSIONS

A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.

Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit

BACKGROUND AND OBJECTIVES

Immediate breast reconstruction (IBR) represents a fundamental part in the management of patients receiving mastectomy. In recent years, there has been an increasing trend in the use of IBR in all age groups. The study aims were to evaluate the age-specific trend of IBR, and to discuss its effects in work organization at an Italian Breast Unit.

METHODS

We searched for women diagnosed with breast cancer between 2010 and 2019, focusing on IBR rates in patients who received mastectomy. Age-specific trends were assessed using the Cochrane-Armitage test. Differences in operative times and hospital stay between women undergoing mastectomy + IBR (Ma + IBR) or mastectomy alone (Ma) were evaluated by Student's t test or χ2 test.

RESULTS

Among 1915 patients, 62.4% underwent breast conserving surgery (BCS), and 37.6% mastectomy. Overall, rates of Ma + IBR increased from 32% in 2010 to 58% in 2019 (p < 0.001). Although rates of IBR rose in all age groups, the trend was significantly increased among patients aged 50-59 (p < 0.001), 60-69 (p < 0.0001), and 70-79 (p < 0.05).

CONCLUSIONS

Rates of Ma + IBR have increased over years, especially among older women. Ma + IBR resulted in longer operative times and hospital stay than Ma alone. These findings imply that, in the near future, resources should be implemented to improve and strengthen the surgical activity of Breast Units, to support the increasing use of IBR in women of all age groups.

Current trends in postmastectomy breast reconstruction

PURPOSE OF REVIEW

Breast reconstruction is established as integral part of the treatment. New materials, indications and surgical techniques are subject to rapid modification to further improve safety, quality and longevity.

RECENT FINDINGS

Skin-sparing-mastectomy is accepted as an appropriate alternative in risk-reducing and many breast cancer patients, further reducing conventional mastectomy patterns.Radiation in combination with reconstruction is still challenging with no clear advances reducing skin-toxicity.Autologous reconstructions, not only in radiation settings, are turning to a first line approach. A trend driven by improved techniques to minimize morbidity and flap-variations.Breast implant surfaces associated with a high risk of Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are now withdrawn. The residual risk for the remaining implant styles is not known, but can be expected considerably lower than estimations published presently.In order to reduce local complications, supplemental material often in combination with prepectoral implant placement is advertised. The present evidence on long-term outcome is limited.Super-microsurgery treating lymphedema is evolving rapidly. Refinements of various techniques and their differential indication are under evaluation to standardize the procedures.

SUMMARY

Breast reconstruction evolved to a complex, specialized field with a multitude of options. A multidisciplinary team is required to fully utilize todays potential and offer optimal individual treatments.

[Change of Gaze Pattern depending on the Stage of DIEP Flap Breast Reconstruction: a Preliminary Eye-Tracking Investigation]

BACKGROUND

Breast reconstruction using autologous tissue is an integral part of breast cancer treatment. While many studies have elucidated the impact of breast reconstruction on patients' quality of life, self-esteem, sexuality and more, there is a lack of objective data regarding the effects on external observers. Aim of this study was to investigate the change in gaze pattern of independent observers depending on the stage of DIEP-flap breast reconstruction.

MATERIALS AND METHODS

Eye-tracking technology was utilized to analyze the eye movements of 58 study participants while viewing 2 D photographs of a patient after mastectomy and different stages of DIEP-flap breast reconstruction. Time until first fixation and total time of fixation were recorded and con- secutively analyzed for the right and left breast on each image.

RESULTS

Overall, the total time of fixation of the operated breast decreased significantly over the different stages of breast reconstruction, with p<0.001. At the same time, there was no statistically significant change in total time of fixation of the non-operated breast, with p=0.174. The time until first fixation showed a significant increase over the different stages of reconstruction for the reconstructed breast, with p<0.001, while no significant differences were found for the opposite breast, with p=0.344.

CONCLUSION

Mastectomy and the individual steps of breast reconstruction alter the perception of breast cancer patients. Over the course of breast reconstruction, the deviation of gaze in the direction of the affected breast is reversed.

ESPRAS Survey on Continuing Education in Plastic, Reconstructive and Aesthetic Surgery in Europe

BACKGROUND

Specialty training in plastic, reconstructive and aesthetic surgery is a prerequisite for safe and effective provision of care. The aim of this study was to assess and portray similarities and differences in the continuing education and specialization in plastic surgery in Europe.

MATERIAL AND METHODS

A detailed questionnaire was designed and distributed utilizing an online survey administration software. Questions addressed core items regarding continuing education and specialization in plastic surgery in Europe. Participants were addressed directly via the European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). All participants had detailed knowledge of the organization and management of plastic surgical training in their respective country.

RESULTS

The survey was completed by 29 participants from 23 European countries. During specialization, plastic surgeons in Europe are trained in advanced tissue transfer and repair and aesthetic principles in all parts of the human body and within several subspecialties. Moreover, rotations in intensive as well as emergency care are compulsory in most European countries. Board certification is only provided for surgeons who have had multiple years of training regulated by a national board, who provide evidence of individually performed operative procedures in several anatomical regions and subspecialties, and who pass a final oral and/or written examination.

CONCLUSION

Board certified plastic surgeons meet the highest degree of qualification, are trained in all parts of the body and in the management of complications. The standard of continuing education and qualification of European plastic surgeons is high, providing an excellent level of plastic surgical care throughout Europe.

HINTERGRUND

Die Facharzt-Weiterbildung für Plastische und Ästhetische Chirurgie ist eine Grundvoraussetzung für sichere und effektive Patientenversorgung. Ziel der vorliegenden Studie war die Darstellung von Gemeinsamkeiten und Unterschieden in der Weiterbildung für Plastische Chirurgie innerhalb von Europa.

MATERIALIEN UND METHODEN

Ein internetbasierter Fragebogen wurde mit Hilfe eines kostenlosen Formularerstellungstools erstellt und verteilt. Die Fragen betrafen Kernpunkte der Weiterbildung für Plastische Chirurgie in Europa. Die Teilnehmer wurden direkt über das European Leadership Forum (ELF) der European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) kontaktiert. Alle Teilnehmer hatten weitreichende Kenntnisse über die Organisation und Struktur der plastisch-chirurgischen Weiterbildung in ihrem jeweiligen Land.

ERGEBNISSE

29 Teilnehmer*innen aus 23 europäischen Ländern nahmen an der Umfrage teil. Die Weiterbildung für Plastische Chirurgie beinhaltet grundlegende Prinzipien und Techniken zur Wiederherstellung von Form und Funktion innerhalb der verschiedenen Säulen der Plastischen Chirurgie, sowie in allen Körperregionen. In den meisten europäischen Ländern ist eine Rotation in der Intensiv- und Notfallmedizin und die Behandlung kritisch kranker Patienten obligatorisch. Voraussetzung für die Facharztbezeichnung ist die mehrjährige, national organisierte Weiterbildung, der Nachweis einer festgelegten Anzahl selbstständig durchgeführter Operationen, sowie die mündliche und/oder schriftliche Abschlussprüfung.

SCHLUSSFOLGERUNG

Fachärzte für Plastische und Ästhetische Chirurgie sind hochqualifiziert und auch im Umgang mit Komplikationen geschult. Der Standard der Weiterbildung der europäischen Plastischen Chirurgen ist hoch, so dass innerhalb Europas eine hohe Qualität plastisch-chirurgischer Versorgung gewährleistet ist.

Fat Grafting following Internal Tissue Expansion: An Option for Breast Reconstruction after Total Mastectomy

Background:

Breast reconstruction is currently performed as standard practice.

Methods:

A prospective study was performed of patients after total mastectomy who underwent autologous breast reconstruction with fat grafting (FG) combined with internal tissue expansion between September 2015 and December 2020. The patients were classified into groups A to F depending on the steps of breast reconstruction. Groups A and B described patients with completed breast reconstruction with FG and expander removal, with or without nipple/areola complex reconstruction. C described patients during deflation of the expander combined with simultaneous FG. D described patients after expander implantation and refilling. E described patients after first FG, and F included patients who discontinued reconstruction with the described method and converted to reconstruction with a breast implant.

Results:

Among 22 treated patients‚ two were after first FG (9.09%‚ group E), two were after expander implantation and refilling (9.09%‚ group D), three were during deflation of the expander combined with simultaneous FG (13.63%‚ group C), and four (18.18%) had completed breast reconstruction—two (9.09%) without NAC reconstruction and symmetrization (group B) and two (9.09%) with completed breast reconstruction (group A). In 11 patients (50%), breast reconstruction was abandoned after expander implantation and one to three FG procedures (group F), converting to breast reconstruction with a breast implant.

Conclusions:

This study demonstrated successful breast reconstruction using FG and expander implantation. Breast reconstruction using this method is safe and enables possible abandonment at any treatment stage, as well as conversion to breast reconstruction with implants.