Results of immediate breast reconstruction after skin-sparing mastectomy

Comparing Wise Pattern to Non-Wise Pattern Skin-Sparing Mastectomy: A Critical Evaluation of Patient Demographics and Surgical Outcomes

BACKGROUND

Multiple skin-sparing incisions are used in immediate postmastectomy breast reconstruction; however, the Wise pattern incision (WPI) may have superior cosmetic outcomes for large, ptotic breasts compared with the non-Wise pattern incision (NWPI). The authors evaluated patient demographics and surgical outcomes with WPI versus NWPI.

METHODS

An electronic medical record search was performed for patients at a single academic institution from 2019 to 2022 with International Classification of Diseases, 10th Revision, Clinical Modification diagnosis code Z42.1: "Encounter for breast reconstruction following mastectomy." Retrospective chart review evaluated patient demographics, intraoperative factors, postoperative complications, and surgical cost.

RESULTS

A total of 288 patients were included: 58 underwent WPI and 230 underwent NWPI. Median body mass index (BMI) differed between WPI (30.5 kg/m 2 ) and NWPI (26.4 kg/m 2 ) ( P < 0.001). Fifty-seven percent of WPI had preoperative grade 3 ptosis versus 23% of NWPI ( P < 0.001). No difference was found in median operative times (WPI, 219 minutes; NWPI, 194 minutes; P = 0.38). Overall rates of postoperative complications differed between WPI (62%) and NWPI (45%) on univariate but not multivariate analysis. Median total surgery charge was higher for WPI (WPI, $36,223; NWPI, $31,185; P < 0.001), whereas implant cost was higher for NWPI (WPI, $2700; NPWI, $8040; P < 0.001).

CONCLUSIONS

There was no significant difference in operative time, overall complication rate, or charge between incision types once adjusted for confounding factors. The higher complication rate in the WPI group was likely driven by higher BMI, a known risk factor for surgical complications regardless of approach. Surgeons can consider WPI as a noninferior option for patients with higher BMI and ptosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Not All Deep Inferior Epigastric Artery Perforator Flaps Are Created Equal: A Review of Donor-site Morbidity in Abdominally Based Autologous Breast Reconstruction

Background

Breast reconstruction after mastectomy is one of the most common procedures performed in plastic surgery. Autologous reconstruction is associated with better long-term patient satisfaction than implant-based reconstruction but with the requisite donor site and potential for associated morbidity.

Methods

The authors review the literature regarding the technical evolution of abdominally based autologous breast reconstruction and the effect of these changes as well as patient morbidities on bulge, hernia, and all-cause donor-site morbidity.

Results

The impact of patient risk factors on surgical outcomes is evaluated in the context of constantly improving technical surgical innovation. Patients' premorbid abdominal condition and prior abdominal procedures along with traditional complicating factors such as age, obesity, and smoking are associated with increased rates of donor-site complications. Conversely, shorter fascial incisions with or without robotic and laparoscopic assistance are associated with lower rates of abdominal weakness and healing complications than traditional abdominal free flap harvest. Perforator selection and abdominal closure techniques also play a key role.

Conclusions

There are contributions of both patient factors and technical aspects that when optimized can help minimize the risk of donor-site morbidity in deep inferior epigastric artery perforator flap breast reconstruction.

Conversion from Alloplastic to Autologous Breast Reconstruction: What Are the Inciting Factors?

Introduction: Failure of alloplastic breast reconstruction is an uncommon occurrence that may result in abandonment of reconstructive efforts or salvage with conversion to autologous reconstruction. The purpose of this study was to identify factors that predict failure of alloplastic breast reconstruction and conversion to autologous reconstruction. Methods: A retrospective chart review was conducted of patients who underwent mastectomy and immediate alloplastic breast reconstruction between 2008 and 2019. Inclusion criteria included patients 18 years or older who underwent initial alloplastic reconstruction with a minimum of 3-year follow-up. Data collected included age, body mass index, cancer type, surgical characteristics, neo/adjuvant treatment details, and complications. Results were analyzed using Fischer's exact test, t-test, and multivariate logistic regression. Results: A total of 234 patients met inclusion criteria. Of those, 23 (9.8%) required conversion from alloplastic to autologous reconstruction. Converted patients had a mean age of 50.1 ± 8.5. The time from initial alloplastic reconstruction to conversion was 30.7 months. The most common reasons for conversion included soft tissue deficiency (48%), infection (30%), and capsular contracture (22%). Patients were converted to deep inferior epigastric perforator flap (DIEP; 52%), latissimus dorsi flap with implant (26%), and DIEP with implant (22%). Multivariate logistic regression modeling identified radiation (OR 8.4 [CI = 1.7-40.1]) and periprosthetic infection (OR 14.6 [CI = 3.4-63.8]) as predictors for conversion. Conclusions: Among patients undergoing mastectomy with immediate alloplastic breast reconstruction, those treated with radiation have 8.4 greater odds of conversion and those with a periprosthetic infection have 14.6 greater odds for conversion to an autologous reconstruction.

Loco-regional recurrence after skin and nipple-sparing mastectomy and immediate breast reconstruction using free flap autologous tissue in a single institution

BACKGROUND

Immediate autologous tissue breast reconstruction after skin- and nipple-sparing mastectomy, is becoming increasingly popular, while the benefits are evident, the concern is in leaving breast tissue under the skin envelope, which could potentially lead to a higher chance of recurrence. We aim to determine the incidence and study the management of loco-regional recurrence (LR) of breast cancer following immediate autologous free flap reconstruction (AFFR) from a 10-year database at a single tertiary breast unit.

METHODS

This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent AFFR between July 2008 and December 2018. All patients undergoing delayed reconstruction and risk-reducing surgery were excluded, leaving a total of 216 patients. Statistical analysis was performed to determine significance in the prediction of LR. Management and outcome of the LR was also studied.

RESULTS

LR was found in 7/216 cases (3.25%). The median age at surgery for patients with LR, was 45 (range 31-54). Median time to recurrence was 54 months (7-79 months). Three patients presented with self-detected lesions. In all, 6/7 patients were ER/PR positive, 2/7 were HER2 + at recurrence, and 1/7 was triple negative. All patients underwent surgical excision for the LR followed by radiotherapy, either chemotherapy (n-5) and/or hormone therapy (n-2). No patients have developed further LR. Because of low numbers of recurrences, no statistical significance was observed for factors causing recurrence.

CONCLUSION

The low LR we report demonstrates that immediate AFFR is oncologically safe. Timely recognition through post-reconstruction patient education and appropriate management results in good outcomes.

Passot-Type Immediate Breast Reconstruction Obviates the Use of Aceullular Dermal Matrix in Grades 2 and 3 Ptosis

PURPOSE

Acellular dermal matrices (ADMs) are commonly used for immediate breast reconstruction after skin-sparing mastectomy (SSM). Regnault grades 2 and 3 ptotic breasts feature significant mastectomy flap redundancy that may be incorporated into the reconstruction. This allows surgeons to use patients' de-epithelialized inferior dermal pedicle instead of ADM.

METHODS

All consecutive SSM patients with Regnault grade 2 or 3 ptosis who underwent Passot-type immediate breast reconstruction (IBBR) with tissue expanders (TEs) and de-epithelialized inferior dermal pedicle without an ADM were included. Patient data from the electronic medical record, clinical photographs, and a comparative cost analysis of ADM versus additional operative time are provided.

RESULTS

Thirty-eight patients with an average age of 52.7 years, weight 210.5 lb, and body mass index of 35.1 kg/m were treated (34 bilateral, 4 unilateral; 72 reconstructed breasts). Average mastectomy specimens weighed 962.8 g. Tissue expanders were filled to 265.0 mL (41.6% capacity) intraoperatively, and final implant volume averaged 710.9 ± 118.5 mL after an average of 628.6 ± 74.1-mL expansion. Operative times for Passot-type IBBR was 124.3 ± 37.7 versus 92.5 ± 27.9 minutes (P = 0.0001) for submuscular TE placement with ADM. The operative technique is described in detail. There were 8 TE explantations (21.1%) included: intractable infection (10.5%; n = 4), symptomatic capsular contracture (7.9%; n = 3), and spontaneous TE deflation (2.6%; n = 1). All but 3 patients (92.1%) successfully completed Passot reconstruction, with 2 patients declining salvage latissimus dorsi flap reconstruction and 1 patient lost to follow-up. Total cost savings in this case series was $89,724 ($2361 ± $3529/case).

CONCLUSIONS

Additional prospective comparison studies are needed to determine whether Passot-type IBBR results in higher complication rates than conventional IBBR with ADM in this challenging patient population. Passot-type IBR after SSM is safe, demonstrates acceptable rates of successful breast reconstruction, confers cost savings by obviating the use of ADM, and provides favorable aesthetic results.

Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi breast reconstruction: A review of patient satisfaction

BACKGROUND

Nipple-areolar complex (NAC) reconstruction following curative mastectomy is traditionally performed as a second-stage procedure several months after initial breast reconstruction. The recent literature has documented the increasing popularity of immediate nipple reconstruction carried out simultaneously during autologous reconstruction. The aim of this study was to evaluate the surgical outcomes and patient satisfaction with immediate breast and nipple reconstruction performed in a single stage after skin-sparing mastectomy.

METHODS

All patients who underwent a skin-sparing mastectomy with immediate latissimus dorsi flap breast and NAC reconstruction as a single-stage procedure from 2007 to 2015 were included. Patient demographics, oncologic details, and surgical outcomes were recorded. The BREAST-Q questionnaire was administered to patients to assess the impact and effectiveness of this reconstructive strategy.

RESULTS

During the study period, 34 breast and NAC reconstructions in 29 patients were performed at Cork University Hospital. The majority of our patient cohort were non-smokers (93.1%) and did not receive adjuvant radiotherapy. Postoperative complications were infrequent, with no cases of partial necrosis or complete loss of the nipple. The response rate to the BREAST-Q was 62% (n=18). Patients reported high levels of satisfaction with the reconstructed breast (62±4), nipple reconstruction (61±4.8), overall outcome (74.3±5), and psychosocial well-being (77.7±3.2).

CONCLUSIONS

Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi reconstruction was demonstrated to be a safe and aesthetically reliable procedure in our cohort, yielding high levels of psychological and physical well-being. A single-stage procedure promotes psychosocial well-being involving issues that are intrinsically linked with breast cancer surgery.

A Prospective Study of Immediate Breast Reconstruction with Laser-Assisted Indocyanine Green Angiography

BACKGROUND

Complication rates following immediate breast reconstruction range from 4% to 60%. Mastectomy skin flap necrosis (MSFN) is often the sentinel event leading to secondary complications.

METHODS

All patients undergoing immediate reconstruction were enrolled. Upon mastectomy completion, the surgeon visually interpreted the skin flaps, performed laser-assisted indocyanine green angiography (LAIGA), and intervened if needed. Patients were followed for 90 days, documenting skin necrosis, infection, seroma, hematoma, implant loss, and reoperation.

RESULTS

There were 126 patients who had 206 immediate breast reconstructions. The complication rate was 22.3%. The incidence of MSFN was 14.1%. The reoperation rate was 8.7%. There was 1 necrosis-related implant loss. Postoperative surveys were completed on 193 breasts: 137 had visual and LAIGA interpretation of well or adequately perfused, resulting in 5.8% rate of necrosis, 2 reoperations, and no implant losses. Twenty breasts had visual and LAIGA interpretation of marginal or poor perfusion. Sixteen of these underwent intervention. The necrosis rate in this group was 35% with no implant losses. A third group with 26 breasts had adequate visual interpretation with marginal or poor perfusion on LAIGA. Ten breasts had no intervention, and 16 received intervention. The overall necrosis rate in this group was 42.3%, with 4 reoperations for necrosis and 1 implant loss.

CONCLUSIONS

LAIGA can more accurately predict complications from MSFN than surgeon assessment alone. When surgeon decision making is supplemented with LAIGA, it reduces the incidence of MSFN, infection, implant loss, and overall unexpected reoperation rate. LAIGA is a valuable adjunct for intraoperative decision making.

Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction

BACKGROUND

Two-stage tissue expander-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure.

METHODS

A retrospective review of tissue expander-based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap.

RESULTS

A total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation).

CONCLUSIONS

Women with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.

A Prospective Study on Skin-Sparing Mastectomy for Immediate Breast Reconstruction with Latissimus Dorsi Flap After Neoadjuvant Chemotherapy and Radiotherapy in Invasive Breast Carcinoma

BACKGROUND

Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) is increasingly used in invasive breast cancer. However, adjuvant chemotherapy (CT) and radiotherapy (RT) can increase the rate of local complications.

OBJECTIVE

The aim of this study was to assess the morbidity of SSM-IBR after neoadjuvant CT and RT.

METHODS

A French prospective pilot study of women aged 18-75 years with invasive breast cancer requiring mastectomy after CT and RT. Reconstruction was performed using autologous latissimus dorsi flap with or without prosthesis. The primary endpoint was the skin necrosis rate within 6 months, while secondary endpoints included pathological complete response rate (pCR) and global morbidity.

RESULTS

Among 94 patients included in this study, 83 were analyzed (mean age 45.2 ± 9.5 years, T1 23.6 %, T2 55.6 %, T3 18.1 %). All but one patient received anthracyclines and taxanes, and all patients received RT (49.3 ± 5.2 Gy) before SSM-IBR. Prostheses were used for IBR in 32 patients (mean volume 256 ± 73 mm(3)). Five patients had necrosis (≤2 cm(2), 2-10 cm(2) and >10 cm(2), in three, one, and one cases, respectively), and they all recovered without revision surgery. Among 50 patients who underwent upfront mastectomy, 36 % achieved pCR.

CONCLUSIONS

SSM-IBR performed after CT and RT is safe, with an acceptable local morbidity rate. Long-term data are needed to evaluate recurrence rates.

Does acellular dermal matrix really improve aesthetic outcome in tissue expander/implant-based breast reconstruction?

BACKGROUND

The expectation for improved results by women undergoing postmastectomy reconstruction has steadily risen. A majority of these operations are tissue expander/implant-based breast reconstructions. Acellular dermal matrix (ADM) offers numerous advantages in these procedures. Thus far, the evidence to justify improved aesthetic outcome has solely been based on surgeon opinion. The purpose of this study was to assess aesthetic outcome following ADM use in tissue expander/implant-based breast reconstruction by a panel of blinded plastic surgeons.

METHODS

Mean aesthetic results of patients who underwent tissue expander/implant-based breast reconstruction with (n = 18) or without ADM (n = 20) were assessed with objective grading of preoperative and postoperative photographs by five independent blinded plastic surgeons. Absolute observed agreement as well as weighted Fleiss Kappa (κ) test statistics were calculated to assess inter-rater variability.

RESULTS

When ADM was incorporated, the overall aesthetic score was improved by an average of 12.1 %. In addition, subscale analyses revealed improvements in breast contour (35.2 %), implant placement (20.7 %), lower pole projection (16.7 %), and inframammary fold definition (13.8 %). Contour (p = 0.039), implant placement (p = 0.021), and overall aesthetic score (p = 0.022) reached statistical significance. Inter-rater reliability showed mostly moderate agreement.

CONCLUSIONS

Mean aesthetic scores were higher in the ADM-assisted breast reconstruction cohort including the total aesthetic score which was statistically significant. Aesthetic outcome alone may justify the added expense of incorporating biologic mesh. Moreover, ADM has other benefits which may render it cost-effective. Larger prospective studies are needed to provide plastic surgeons with more definitive guidelines for ADM use.

LEVEL OF EVIDENCE IV

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 .

Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals

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.

Short-term outcomes of immediate breast reconstruction using an implant or tissue expander after mastectomy in breast cancer patients

BACKGROUND

Mastectomy is an optional surgical management of breast cancer, but it can cause significant adverse reactions. Breast reconstruction is a concern in post-mastectomy recovery. We assessed the oncologic safety and patient satisfaction following immediate breast reconstruction using an implant or tissue expander.

METHODS

We retrospectively reviewed all patients who underwent reconstruction with an implant or tissue expander immediately after mastectomy. Seventy-seven patients underwent breast reconstruction at a general hospital breast cancer center from January 2008 to December 2010. Fourteen patients were excluded due to loss at follow-up, so 63 patients were included in this study. Questionnaires were sent to all patients to assess patient satisfaction.

RESULTS

Mean age was 44.1 years (range 29-64). After a median follow-up period of 22.4 months, there was 1 case of locoregional recurrence, 1 case of distant metastasis, and an overall breast cancer-specific survival of 100 %. Overall rate of major complications, such as nipple areolar complex (NAC) necrosis and implant removal, was 11.1 % (7 patients). Of the 10 patients who had NAC necrosis, 6 patients improved after observation and 4 patients had NAC excision. Three patients had their implant removed due to severe infection, leakage, and dissatisfaction, respectively. There were 32 cases of total mastectomy (TM), 12 cases of skin-sparing mastectomy (SSM), and 19 cases of NAC-sparing mastectomy (NSM). According to the questionnaire, 84.1 % were satisfied with the general operational result and 77.8 % with the cosmetic result. Of the 31 patients who received conservative surgery, 87.1 % were satisfied with the general result and 83.9 % with the cosmetic result.

CONCLUSIONS

Immediate breast reconstruction using an implant after mastectomy was technically feasible and oncologically safe. In addition, the reconstruction resulted in a relatively high rate of patient satisfaction. Further long-term studies are warranted to confirm these findings.

Radiotherapy and breast reconstruction: oncology, cosmesis and complications

Breast reconstruction plays a highly important role in the management of patients with breast cancer, from a psycho-social and sexual stand-point. Given that immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiotherapy, the need to balance cosmesis in reconstruction with the oncologic needs of breast cancer patients is no more evident than in the discussion of radiotherapy. Radiotherapy is essential adjuvant therapy in the treatment of breast cancer, with the use of adjuvant radiotherapy widely shown to reduce local recurrence after both partial and total mastectomy and shown to prolong both disease-free and overall survival in patients with nodal disease. In the setting of breast reconstruction, the effects of radiotherapy are potentially two-fold, with consideration required of the impact of breast reconstruction on the administration of and the initiation of radiotherapy, as well as the effects of radiotherapy on operative complications and cosmetic outcome following immediate breast reconstruction. The current editorial piece aims to analyze this balance, contrasting both autologous and implant-based reconstruction. The literature is still evolving as to the relative role of autologous vs. alloplastic reconstruction in the setting of radiotherapy, and the more recent introduction of acellular dermal matrix and other compounds further complicate the evidence. Fat grafting and evolving techniques in breast reconstruction will herald new discussions on this front.

Oncoplastic surgery in the treatment of breast cancer

Advances in reconstructive breast surgery with new materials and techniques now allow us to offer our patients the best possible cosmetic results without the risks associated with oncological control of the disease. These advances, in both oncological and plastic surgery, have led to a new specialisation, namely oncoplastic breast surgery, which enables us to undertake large resections and, with advance planning, to prevent subsequent deformities. This is particularly important when more than 30% of the breast volume is removed, as it allows us to obtain precise information for conservative surgery according to the site of the lesion, and also allows us to set the boundary between conservative surgery and mastectomy.Given the existence of new alloplastic materials and new reconstructive techniques, it is essential for our patients that surgeons involved in breast cancer treatment are trained in both the oncological as well as the reconstructive and aesthetic fields, to enable them to provide the best loco-regional treatment with the best cosmetic results.

Nipple-sparing mastectomy: technical aspects and aesthetic outcomes

INTRODUCTION

Nipple-sparing mastectomy (NSM) is increasingly used to improve the results of immediate breast reconstruction. Technical aspects and aesthetic outcomes of this procedure are examined.

METHODS

A study of a prospective institutional database of all cases of NSM between 2009 and 2010 was performed. Aesthetic outcomes (symmetry, inframammary fold, volume, contour, and nipple) are compared with patients undergoing skin-sparing mastectomy and immediate breast reconstruction by grading postoperative photographs. Technical refinements in incision types and nipple positioning are described.

RESULTS

Twenty-six patients underwent 40 NSMs during the study period. Partial nipple necrosis occurred in 15 breasts (37.5%); of them, 14 healed uneventfully with local wound care, and 1 patient required delayed nipple reconstruction. Nipple necrosis by incision type was radial/circumareolar in 6 of 8 (75%) patients; radial, 3 of 9 (33.3%); inframammary fold, 6 of 22 (27.3%); and vertical, 0 of 1 (0%). The nipple aesthetic outcome was significantly better for NSM compared with nipple reconstruction after skin-sparing mastectomy (P = 0.01).

CONCLUSIONS

The incidence of partial nipple necrosis was high and was related to circumareolar incisions. Most cases of nipple necrosis are superficial and heal uneventfully. Preservation of the nipple improves the aesthetic outcome of immediate breast reconstruction.

Does hyperbaric oxygen administration before or after irradiation decrease side effects of irradiation on implant sites?

BACKGROUND

One of the main limitations of implant-based breast reconstruction is the high rate of complications such as capsular contracture and poor aesthetic outcome, due to adjuvant radiotherapy. Hyperbaric oxygen treatment (HBOT) has been used to assist wound healing in the prevention and treatment of the side effects of irradiation. We aimed to investigate this effect of HBOT on the capsule reaction and skin, applied before and after irradiation, following the placement of an implant under the dorsal skin of the rat.

METHODS

Fifteen Wistar rats were randomly divided into 3 groups. A 18-mL smooth testicular implant was introduced into a subcutaneous pocket located on the dorsum of each rat. A single dose of 17-Gy irradiation was given to the implanted area of each rat at the third week. HBOT which lasted 3 weeks was administered to group I before irradiation, group II after irradiation. The control group did not receive HBOT. All of the rats were killed at the ninth week (6 weeks after irradiation). The dorsal skin with the capsule overlying the implant were excised for histopathological processing. The thickness of the capsule reaction of each group was evaluated statistically.

RESULTS

Our histopathological examination revealed changes due to radiation in the control group. Many of these findings were found to be more subtle in group I and nearly absent in the group II. There was not any statistical difference between the thickness of the capsule reactions of the control group and group I, or group I and group II, but the capsular thickness of the control group was statistically higher than group II.

CONCLUSION

It can be predicted that the use of HBOT following irradiation is an effective tool to reduce the capsule reaction of the implanted area and the tissue damage seen in radiodermatitis.

Skin banking: treatment option for native skin necrosis following skin-sparing mastectomy and previous breast irradiation

Skin flap necrosis, as well as positive resection margins in the context of skin-sparing mastectomy and immediate breast reconstruction, may require reoperation, potentially associated with tissue loss, and thereby impair the aesthetic result. Skin banking has recently been described as a method for handling skin flaps of uncertain viability. Here, we describe the advantages of skin banking in previously irradiated patients with breast cancer recurrence, which underwent skin-sparing mastectomy and immediate breast reconstruction. Aside from its utility in the management of skin necrosis, we present this method as an option to conserve the native breast shape in patients with questionable total resection during surgery.

An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm)

BACKGROUND

The advent of skin- and nipple-sparing mastectomy in conjunction with the use of human acellular dermal matrix to provide lower pole coverage has made direct-to-implant immediate breast reconstruction following mastectomy feasible. The purpose of this study was to evaluate long-term complications associated with this technique.

METHODS

All human acellular dermal matrix-assisted direct-to-implant immediate reconstructions performed over an 8-year period were included in this analysis. Patient charts were reviewed for type of mastectomy (oncologic or prophylactic), incision type, complications during follow-up, length of follow-up, rate and type of revision surgery in breasts without postoperative complications, contralateral procedures, and adjuvant radiotherapy.

RESULTS

A total of 466 breasts (260 patients) were reconstructed; 68 percent were prophylactic and 32 percent were oncologic cases. Twenty-one breasts (4.5 percent) received radiotherapy. Mean implant size placed was 412.8 ± 24.7 cc (range, 150 to 600 cc). Mean follow-up was 28.9 ± 21.3 months (range, 0.3 to 97.7 months). The overall complication rate was 3.9 percent (implant loss, 1.3 percent; skin breakdown/necrosis, 1.1 percent; hematoma, 1.1 percent; human acellular dermal matrix exposure, 0.6 percent; capsular contracture, 0.4 percent; and infection, 0.2 percent). Type, incidence, and overall rate of complications did not differ significantly between prophylactic and oncologic breasts. Irradiated breasts had a fourfold higher rate of complications. In 354 breasts with more than 1 year of follow-up (mean, 36.7 ± 18.6 months; range, 12.1 to 97.7 months), there were no long-term complications.

CONCLUSIONS

Human acellular dermal matrix-assisted direct-to-implant breast reconstruction following mastectomy is safe and reliable, with a low overall long-term complication rate. The low incidence of capsular contracture supports the growing body of evidence that human acellular dermal matrix mitigates capsular contracture.

Reporting clinical outcomes of breast reconstruction: a systematic review

BACKGROUND

Breast reconstruction after mastectomy for cancer requires accurate evaluation to inform evidence-based participatory decision making, but the standards of outcome reporting after breast reconstruction have not previously been considered.

METHODS

We used extensive searches to identify articles reporting surgical outcomes of breast reconstruction. We extracted data using published criteria for complication reporting modified to reflect reconstructive practice. Study designs included randomized controlled trials, cohort studies, and case series. The Cochrane Risk of Bias tool was used to critically appraise all study designs. Other criteria used to assess the studies were selection and funding bias, statistical power calculations, and institutional review board approval. Wilcoxon signed rank tests were used to compare the breadth and frequency of study outcomes, and χ² tests were used to compare the number of studies in each group reporting each of the published criteria. All statistical tests were two-sided.

RESULTS

Surgical complications following breast reconstruction in 42,146 women were evaluated in 134 studies. These included 11 (8.2%) randomized trials, 74 (55.2%) cohort studies, and 49 (36.6%) case series. Fifty-three percent of studies demonstrated a disparity between methods and results in the numbers of complications reported. Complications were defined by 87 (64.9%) studies and graded by 78 (58.2%). Details such as the duration of follow-up and risk factors for adverse outcomes were omitted from 47 (35.1%) and 58 (43.3%) studies, respectively. Overall, the studies defined fewer than 20% of the complications they reported, and the definitions were largely inconsistent.

CONCLUSIONS

The results of this systematic review suggest that outcome reporting in breast reconstruction is inconsistent and lacks methodological rigor. The development of a standardized core outcome set is recommended to improve outcome reporting in breast reconstruction.

Sentinel lymph node biopsy in breast cancer patients undergoing skin/nipple-sparing mastectomy and immediate autologous reconstruction

Immediate breast reconstruction following mastectomy is an effective treatment for breast cancer patients. Among several implant options, a latissimus dorsi myocutaneous (LDM) flap is used mainly due to the ease and minimal invasiveness of the procedure. The role of sentinel lymph node (SLN) biopsy with total mastectomy is evolving. Since SLN biopsy is not included in health insurance coverage in the treatment of patients in Japan, it is not generally performed as a separate procedure due to its cost. The present study reviewed the results of seven patients who underwent initial-staged SLN biopsy followed by planned mastectomy and LDM flap reconstruction. Two patients with positive SLNs showed macrometastases and underwent modified radical mastectomy with immediate reconstruction. In contrast, cases showing negative results for sentinel lymph nodes underwent total mastectomy. There were no false-negative cases among the SLN biopsy-negative cases. When an SLN is found to be positive on final pathology, the patient with reconstruction by LDM flap generally requires a potentially difficult reoperation on the remaining axillary nodes. When initial SLN biopsy is generally performed as a separate procedure in Japan, it will be an effective method for screening the axilla for patients who wish to undergo LDM flap reconstruction.

Long-term outcome after mastectomy with immediate breast reconstruction

INTRODUCTION

The purpose of this study was to investigate long term outcome for women who had undergone mastectomy and immediate breast reconstruction.

MATERIAL AND METHODS

Patient files of 167 immediately reconstructed breast cancer patients were reviewed for late surgical complications. Furthermore, information of local recurrence rate, radiotherapy and death was obtained from the Danish Breast Cancer Cooperative Group register. Histopatological high and low risk patients were compared with respect to locoregional recurrence rate, recurrence free survival and death. Unpaired t-test and Fisher's exact test were used to test for significance.

RESULTS

The overall rate of revision surgery was 27%. Reconstruction with implants was associated with a significantly higher rate of revision surgery compared to reconstructions with transverse rectus abdominis myocutaneous flap or latissimus dorsi flap without implant (36 vs. 14%; p=0.004). The locoregional recurrence rate was 6%. Patients with histopathologically high risk disease had increased death rate (22 vs. 6%; p=0.03) and shorter disease free survival (89+/-43 months vs. 104+/-35 months; p=0.048) compared with low risk disease. We found no increase in the occurrence of capsular contracture in our study group in patients who received radiotherapy.

CONCLUSION

Immediate breast reconstruction seems to be oncologically safe. Breast reconstruction performed with implants was associated with a higher risk of late complications, as was histopathologically high risk disease with increased death rate and shorter disease free survival.

The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study

OBJECTIVE

To find out if skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM) with immediate autologous reconstruction as safe in oncological terms as modified radical mastectomy (MRM).

SUMMARY BACKGROUND

The oncological safety of less radical surgical procedures like SSM and NSM cannot be evaluated by randomized trials. A careful and long lasting follow-up of patients, treated with SSM or NSM, is urgently needed.

PATIENTS AND METHODS

Between 1994-2000, 246 selected patients with an indication for MRM were treated with SSM, NSM, or MRM. Short term results were published in 2003. After a mean follow-up of 101 months (range 32-126), 238 evaluable patients with SSM (N = 48), NSM (N = 60), or MRM (N = 130) were analyzed for local and distant recurrences, breast cancer specific death, and esthetic results.

RESULTS

Local recurrences occurred in 10.4% (SSM), 11.7% (NSM) and 11.5% (MRM) of all patients (P = 0.974). With regard to isolated DM (25.0%, 23.3%, respectively 26.2%; P = 0.916) and breast cancer specific death (20.8%, 21.7%, respectively 21.5%; P = 0.993), there were no significant differences between subgroups. The re-evaluation of esthetic results by surgeons revealed a significant shift from 78.4% excellent results after 59 months to 47.9% after 101 months follow-up (SSM; P = 0.004) and from 73.8% to 51.7% (NSM; P = 0.025). An important risk factor for decreased cosmetic score was application of adjuvant radiotherapy.

CONCLUSION

In patients who are candidates for a mastectomy, skin sparing mastectomy or nipple sparing mastectomy with immediate autologous reconstruction are oncologically safe techniques. Adjuvant radiotherapy decreases the esthetic results even after a longer period of time.

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO)

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.

Immediate skin-sparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome

Although breast reconstruction with deep inferior epigastric perforator (DIEP) flap is a well-described technique, few publications have specifically reported the technical aspects and the outcome following skin-sparing mastectomy (SSM). The aim of this study is to analyse the feasibility of its immediate application and to describe the operative planning, outcome and complications after SSM. 27 patients underwent 30 DIEP flap breast reconstructions with all immediate and 3 bilateral. Mean time of follow-up was 29 months. Breast skin, DIEP Flap and donor-site complications were evaluated. Information on patient satisfaction was collected. 70% had tumors measuring 2 cm or less (T1) and 74% were stage 0 and I according to American Joint Committee on Cancer. Breast skin complications occurred in 7.4%, all represented by small areas of skin necrosis. Partial losses were observed in two (7.4%) patients (less than 15% of total area) and total DIEP loss in 1 (3.7%). Donor-site complications represented by bulging occurred in only one patient (3.7%). The majority of patients were either very satisfied or satisfied. One local recurrence was observed. All complications except 2 were treated by a conservative approach. The DIEP flap is a reliable technique for SSM reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon and careful intraoperative and postoperative management. The main advantage is that patients can safely undergo dual procedures with the added aesthetic benefits in breast and abdominal donor site.

Comparison of Aesthetic Breast Reconstruction After Skin-Sparing or Conventional Mastectomy in Patients Receiving Preoperative Radiation Therapy

Many options exist for the surgical treatment of breast cancer in terms of tumor extirpation and reconstruction. Skin-sparing mastectomy (SSM) with immediate reconstruction offers patients a superior result, but this can be jeopardized by preoperative radiotherapy. We compared the outcomes of reconstruction after SSM or conventional mastectomy (CM) in the previously irradiated breast. We evaluated 41 patients over an 8-year period, who were divided into 3 categories: preoperative radiotherapy prior to SSM (n = 8), CM after preoperative radiation therapy (n = 9), and no chest wall irradiation prior to SSM (n = 20). The first group demonstrated significantly higher frequency of native flap compromise and capsular contracture formation than the other 2 groups.SSM with TRAM or latissimus with implant reconstruction is an esthetically optimal option for the treatment of patients without previous radiotherapy. However, for patients with preoperative chest wall radiation, TRAM flap reconstruction was superior to latissimus flap with implant after SSM.

The pedicled TRAM flap in breast reconstruction

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a viable option in breast reconstruction. This article documents the history of the TRAM flap and puts in context the vascular anatomy through a discussion of the vascular zones. Options for flap delay are discussed and an algorithm is presented for patient selection. Finally, the issue of unipedicle versus bipedicle flap harvest is discussed and complications are examined.

Refinements of the LeJour vertical mammaplasty skin pattern for skin-sparing mastectomy and immediate breast reconstruction

BACKGROUND

Skin-sparing mastectomy (SSM) is a well-established technique for immediate breast reconstruction (IBR). When used for large and/or ptotic breasts, traditional SSM patterns produce long skin flaps prone to necrosis or 'T' junction breakdown. The authors have previously demonstrated the applicability of the LeJour-type vertical mammaplasty skin pattern to this group of patients. With further experience, indications for this procedure have been widened and the technique refined.

RESULTS

Over five years, 26 immediate breast reconstructions were carried out in 19 patients using this technique: three expandable implants, seven LDs, three pedicled TRAMs, five free TRAMs, seven DIEPs and one SIEA flap. Fourteen patients (74%) had simultaneous contralateral balancing LeJour breast reductions or mastopexies. The remaining five patients had bilateral mastectomies and reconstructions using the vertical mammaplasty skin pattern for both breasts. All flaps were successful, but there were three cases of minor skin flap necrosis, three of delayed wound healing and two instances of significant post-operative bleeding. Cosmesis was suboptimal in the prosthetic reconstruction group, necessitating revisional surgery.

DISCUSSION AND CONCLUSIONS

The vertical mammaplasty skin pattern was successfully used with a wide range of reconstructions. However, to avoid suboptimal cosmetic results and minimise wound healing problems this technique is not recommended in heavy smokers, very obese patients, those undergoing prosthetic reconstructions or neoadjuvant chemotherapy. The skin resection pattern should also be conservative. The LeJour-type vertical mammaplasty pattern is a viable alternative technique for SSM in selected patients, especially those requiring contralateral balancing surgery and undergoing autologous tissue reconstruction.

Aesthetic result among breast cancer patients undergoing autologous breast reconstruction versus breast conserving therapy

PURPOSE

Following breast-conserving surgery or mastectomy followed by autologous breast reconstruction, breast cancer patients were studied to discover their satisfaction with the aesthetic results of the two treatment strategies.

PATIENTS AND METHODS

One hundred and thirty-four breast cancer patients were included in this study. Sixty-four underwent breast-conserving surgery followed by radiotherapy. Mastectomy was performed in 70 patients with immediate or late reconstruction. To evaluate the quality of the aesthetic results in both groups we designed a questionnaire assessing different cosmetic categories.

RESULTS

Patients in both therapy groups showed a very high satisfaction with their cosmetic results; the patients undergoing breast reconstruction were even more satisfied than the patients who had breast-conserving therapy.

CONCLUSION

Our study demonstrated that breast reconstruction with autologous tissue offers an opportunity to support patients with advanced breast cancer who were confronted with mastectomy, showing a high degree of satisfaction with the cosmetic results.

Complications after microvascular breast reconstruction: experience with 1195 flaps

BACKGROUND

Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction.

METHODS

All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed.

RESULTS

A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications.

CONCLUSIONS

Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

A Single Surgeon???s 12-Year Experience with Tissue Expander/Implant Breast Reconstruction: Part I. A Prospective Analysis of Early Complications

BACKGROUND

Multiple prior reports are conflicted regarding the true incidence of complications following implant-based breast reconstruction. A review of a single surgeon's extensive experience with tissue expander/implant reconstruction provides the opportunity to critically evaluate outcomes in a uniformly treated patient population. The objective of this study was to analyze the development of early complications in patients following two-stage implant breast reconstruction.

METHODS

A review of all tissue expander/implant reconstructions performed by a single surgeon over the 12-year period from July of 1992 to June of 2004 was performed. A prospectively maintained database was analyzed with respect to reconstructive and early complication data on 1522 reconstructions in 1221 patients. Early complications were defined as those occurring 12 months or less from initiation of reconstruction.

RESULTS

The overall rate of early complications was 5.8 percent; the rate of premature expander removal was 2.7 percent. The most common complication was infection (2.5 percent). The incidence of complications after tissue expander insertion (8.5 percent) was significantly higher than that after the exchange procedure (2.7 percent). The rate of complications was significantly higher in patients with a history of preoperative chest wall irradiation. There was no difference in the incidence of complications in patients who were expanded during chemotherapy and those who were not.

CONCLUSIONS

Tissue expander/implant reconstruction is a safe, reliable method of reconstruction with minimal early complications. Early complications are more common after expander insertion. Chemotherapy administered during tissue expansion does not increase the rate of complications. The rate of complications, although higher in previously irradiated patients, remains low.

Skin-Sparing Mastectomy and Immediate Breast Reconstruction by Use of Implants: An Assessment of Risk Factors for Complications and Cancer Control in 120 Patients

BACKGROUND

Combined skin-sparing mastectomy and immediate reconstruction by use of an implant is increasingly accepted as a therapy for patients with breast cancer or a hereditary risk of breast cancer. Because little and contradictory evidence regarding possible risk factors for postoperative complications is available, the authors retrospectively assessed 13 such factors. They also evaluated the oncological safety of the procedure.

METHODS

From July of 1996 through June of 2000, 174 skin-sparing mastectomies were combined with immediate breast reconstruction in 120 patients. The authors assessed the influence of five patient-related and eight breast-related characteristics on the incidence of a complicated postoperative course by univariate and multivariate analyses. Oncological safety was evaluated by observed recurrent disease and 5-year survival.

RESULTS

Severe complications were observed in 17 patients of the 120 patients (14 percent), or 19 of the 174 breasts (11 percent). The patient-related characteristics of age and being operated on unilaterally significantly increased the risk of complications. Resident plastic surgeons and previous breast-conserving therapy including radiotherapy significantly increased the risk of implant loss. The local relapse rate among patients operated on for cancer was 0.02. The actuarial 5-year survival rate among patients who underwent curative mastectomies was 0.96.

CONCLUSIONS

Combined skin-sparing mastectomy and immediate reconstruction by use of an implant is oncologically safe, but the risk of postoperative complications cannot be neglected. The authors' observations may offer guidance for adapting indication and treatment strategies for patients with breast cancer or increased hereditary risk of such cancer.

A subjective rating scale for evaluating the appearance outcome of autologous breast reconstruction

BACKGROUND

Subjective evaluations of the appearance outcome of autologous breast reconstruction are usually performed by surgeons and not by patients. Such surgeon-based evaluations are rarely reproducible and show little interobserver agreement. Among existing patient-based subjective scales, none has been tested for reliability, and no study to date has evaluated the reliability when both surgeons and patients use the same scale.

METHODS

The authors developed a new instrument for assessing the appearance of autologous breast reconstruction. The instrument's use by four plastic surgeons and 36 transverse rectus musculocutaneous flap patients was assessed for test-retest reliability, internal consistency, surgeon-patient and surgeon-surgeon interobserver agreement, and interitem correlation.

RESULTS

The instrument demonstrated high overall internal consistency when used by patients (Cronbach alpha = 0.92). Test-retest reliability on each aesthetic subitem in the scale was higher among patients than among surgeons (weighted kappa range, 0.57 to 0.88 versus 0.25 to 0.66). Interrater agreement was poor among both patients and surgeons (weighted kappa, 0.0 to 0.39). Poor correlation was found between surgeons' evaluations of aesthetic subitems and patients' overall appearance and overall satisfaction scores.

CONCLUSIONS

The instrument both demonstrates better internal consistency and is more reliable when used by patients to evaluate their own reconstructions. By contrast, the instrument's use by surgeons is not as internally consistent and reproducible. The poor interobserver agreement among surgeons and the weak correlation between surgeon and patient evaluations suggest that patient input regarding item-specific criteria should be included in evaluations of breast reconstructions.