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Escandón JM, Aristizábal A, Christiano JG, Langstein HN, Manrique OJ. Sentinel lymph node biopsy and immediate two-stage implant-based breast reconstruction: A propensity score-matched analysis. J Plast Reconstr Aesthet Surg 2023; 84:447-458. [PMID: 37413737 DOI: 10.1016/j.bjps.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/27/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND There are important differences between patients requiring sentinel lymph node biopsy (SLNB) and those who do not require axillary surgery at the time of breast reconstruction. We aimed to perform a propensity score-matched analysis to evaluate the impact of SLNB at the time of immediate implant-based breast reconstruction (IBBR) with tissue expanders compared with IBBR alone. METHODS Consecutive female patients undergoing total mastectomy and immediate two-stage IBBR between January 2011 and May 2021 were included. A 1:1 nearest-neighbor matching method without replacement was implemented with a caliper width of 0.01. Patients were matched for age, diabetes, hypertension, hyperlipidemia, premastectomy radiotherapy, neoadjuvant chemotherapy, the plane of prosthesis placement, mastectomy specimen weight, number of drains, and radiation of the expander. RESULTS We included 320 two-stage immediate IBBRs after propensity score matching, 160 reconstructions per group. Relevant surgical variables were comparable between groups. A higher rate of 30-day seroma formation was reported in immediate reconstructions that had SLNB at the time of mastectomy compared with reconstructions that did not have axillary surgery (16.3% versus 8.1%, p = 0.039). The time to complete outpatient expansions and time for expander-to-implant exchange were comparable between patients who underwent IBBRs with SLNB and those who did not. CONCLUSION SLNB performed at the time of mastectomy and IBBR with tissue expander increased the risk of seroma formation compared with reconstructions that did not have axillary surgery. The rate of infection, hematoma, and unplanned procedures to manage complications did not differ between groups.
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Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Alejandra Aristizábal
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Jose G Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA.
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Schultz BD, Sultan D, Ha G, Gibstein A, Nguyen K, Barnett SL, Suydam RC, Kasabian AK, Smith ML, Tanna N. Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: A Prospective Study. J Reconstr Microsurg 2022; 38:721-726. [PMID: 35292953 DOI: 10.1055/s-0042-1744503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Accurate assessment of regional lymph node basins is critical for oncological management of breast cancer. The internal mammary lymph node (IMLN) basin directly drains the medial pole of the breast, but biopsy is not commonly performed. While the axillary sentinel lymph node sample remains the standard of care, the majority of patients who have been found to have a positive IMLN biopsy have simultaneously had negative axillary sentinel lymph nodes. This study prospectively examines routine IMLN biopsy during microsurgical breast reconstruction. METHODS An IRB-approved study of routine IMLN biopsies in 270 consecutive patients who underwent microsurgical breast reconstruction was performed from July 1, 2018, to June 1, 2021. Recorded data included unilateral or bilateral breast reconstruction, unilateral or bilateral IMLN sampling, patient demographics, disease stage, and pathologic findings of IMLN. RESULTS The majority of patients, 240 of 270 patients (88.9%), had bilateral reconstruction. Overall, 5 out of 270 (1.9%) patients had positive IMLN; one of these patients had positive axillary sentinel lymph nodes. The IMLN biopsy results in two of the five patients affected the clinical course as they were upstaged and required chemoradiation. CONCLUSION Direct visualization of the internal mammary lymph nodes during dissection of the recipient vessels for microsurgical breast reconstruction allows for convenient sampling, with minimal donor site morbidity and enhances the therapeutic management of patients in whom nodal involvement is present. As such, the authors recommend IMLN sampling.
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Affiliation(s)
- Benjamin D Schultz
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Darren Sultan
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Grace Ha
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Alexander Gibstein
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Khang Nguyen
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Sarah L Barnett
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Rebecca C Suydam
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Armen K Kasabian
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Mark L Smith
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
| | - Neil Tanna
- Division of Plastic and Reconstructive Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Great Neck, New York
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Karanetz I, Jin M, Nguyen K, Delmauro M, Lerman OZ, Smith ML, Tanna N, Kasabian A. Evaluation of internal mammary lymph node biopsy during microsurgical breast reconstruction: An analysis of 230 consecutive patients. Breast J 2020; 27:7-12. [PMID: 33325590 DOI: 10.1111/tbj.14105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Clinical significance of internal mammary (IM) lymph node biopsy during microvascular free flap breast reconstruction remains controversial. Some microsurgeons may choose to biopsy an IM lymph node during routine IM vessel dissection. The authors reviewed the results of IM lymph node biopsy during autologous breast reconstruction. METHODS A retrospective chart review of patients who underwent autologous breast reconstruction during a seven-year period (January 2010 to January 2017) was performed. Patient demographic data, disease staging, flap details, pathology reports, and adjuvant treatment were evaluated. RESULTS A total of 230 patients with a mean age of 52.1 (SD 9.3) underwent IM lymph node biopsy (n = 297). Single IM lymph node was removed in 169 patients, 2 nodes were removed in 56 patients, 3 nodes in 4 patients, and 4 nodes in a single patient. Histopathologic analysis demonstrated presence of IM lymph node metastasis in 16 patients (7.0%). Thirteen patients were found to have metastatic IM lymph nodes in the setting of immediate reconstruction. Three patients were found to have metastatic IM lymph nodes in the setting of delayed. Five out of 16 patients (31.3%) had negative axillary sentinel lymph node biopsy and IM lymph nodes were the only site of nodal metastases. All five of these patients were upstaged accordingly and received adjuvant therapy based on the discussion at the multidisciplinary breast tumor conference. CONCLUSIONS Opportunistic internal mammary lymph node sampling during autologous breast reconstruction can be performed with minimal morbidity and has significant impact on the disease staging and adjuvant treatment.
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Affiliation(s)
- Irena Karanetz
- Long Island Plastic Surgical Group, P.C., Hofstra Northwell School of Medicine, Garden City, NY, USA
| | - Michael Jin
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Khang Nguyen
- Division of Plastic and Reconstructive Surgery at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | | | - Oren Z Lerman
- Department of Plastic and Reconstructive Surgery at Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Mark L Smith
- Division of Plastic and Reconstructive Surgery at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Neil Tanna
- Division of Plastic and Reconstructive Surgery at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Armen Kasabian
- Division of Plastic and Reconstructive Surgery at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
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Yang L, Long J, Li Z, Zhou X, Peng X, Song D, Zhou B, Lv C, Wu P. The lateral thoracic vessels: A novel recipient site for breast reconstruction with DIEP flap. J Plast Reconstr Aesthet Surg 2019; 72:1530-1536. [DOI: 10.1016/j.bjps.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 11/16/2022]
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Breast reconstruction with a turbocharged transverse rectus abdominis myocutaneous flap on the contralateral perforator. Ann Plast Surg 2014; 73:503-8. [PMID: 24625511 DOI: 10.1097/sap.0b013e318276d9f1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Seventeen patients were submitted to delayed unilateral breast reconstruction using pedicled, muscle-sparing turbocharged transverse rectus abdominis myocutaneous flap based on the contralateral perforator vessels. The lateral portion of the rectus abdominis muscle on the pedicled side was preserved in 12 patients. Zones II and IV were included in the flap in all cases. Mean duration of surgery was 7 hours and 15 minutes. Four complications developed in the abdominal donor site: contralateral abdominal bulging (n=1), minor suture dehiscence (n=2), and epidermolysis at the border of the abdominal flap and umbilical scar (n=1). Three partial losses (10%-30%) occurred in the reconstructed breast (17.64% of cases), whereas 2 cases of fat necrosis were associated with partial losses. One patient developed deep vein thrombosis with pulmonary embolism; however, outcome was favorable. This proved a viable alternative for breast reconstruction, with satisfactory results in most patients and acceptable morbidity and surgical time.
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An Assessment of the Risks and Benefits of Immediate Autologous Breast Reconstruction in Patients Undergoing Postmastectomy Radiation Therapy. Ann Plast Surg 2013; 71:149-55. [DOI: 10.1097/sap.0b013e31824b3dcc] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Recipient vessel selection in immediate breast reconstruction with free abdominal tissue transfer after nipple-sparing mastectomy. Arch Plast Surg 2012; 39:216-21. [PMID: 22783529 PMCID: PMC3385346 DOI: 10.5999/aps.2012.39.3.216] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/17/2012] [Accepted: 04/25/2012] [Indexed: 12/12/2022] Open
Abstract
Background Nipple-sparing mastectomy (NSM) is gaining popularity due to its superior aesthetic results. When reconstructing the breast with free abdominal tissue transfer, we must readdress the recipient vessel, because NSM can cause difficulty in access to the chest vessel. Methods Between June 2006 and March 2011, a total of 92 women underwent NSM with free abdominal tissue transfer. A lateral oblique incision was used for the nipple-sparing mastectomy. For recipient vessels, the internal mammary vessels were chosen if the mastectomy flap did not block access to the vessels. If it did, the thoracodorsal vessels were used. Age, degree of breast ptosis, weight of the mastectomy specimen, and related complications of the internal mammary vessel group and the thoracodorsal vessel group were compared. Results Thoracodorsal vessels were used as recipient vessels in 59 cases, and internal mammary vessels in 33 cases including 4 cases with perforators of the internal mammary vessels. Breast reconstruction was successful in all cases except one case involving a total flap failure, which was replaced by a silicone gel implant. The internal mammary group and the thoracodorsal group were similar in terms of age, height, breast weight, and degree of ptosis. The flap related complications such as flap loss and take-back operation rates were not significantly different between the two groups. The rate of nipple necrosis was higher in the internal mammary group. Conclusions The thoracodorsal vessels could produce comparable outcomes in breast reconstruction after nipple-sparing mastectomies. If access to internal mammary vessels is difficult, the thoracodorsal vessel can be a better choice.
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Mannu G, Navi A, Morgan A, Mirza S, Down S, Farooq N, Burger A, Hussien M. Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction may predict post-mastectomy radiotherapy, reduce delayed complications and improve the choice of reconstruction. Int J Surg 2012; 10:259-64. [DOI: 10.1016/j.ijsu.2012.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/24/2012] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
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Tips for Successful Microvascular Abdominal Flap Breast Reconstruction Utilizing the “Total Rib Preservation” Technique for Internal Mammary Vessel Exposure. Ann Plast Surg 2011; 66:36-42. [DOI: 10.1097/sap.0b013e3181e19daf] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jin US, Minn KW. Breast reconstruction using the transverse rectus abdominis musculocutaneous (TRAM) free flap. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2011. [DOI: 10.5124/jkma.2011.54.1.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Won Minn
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
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Wood BC, David LR, Defranzo AJ, Stewart JH, Shen P, Geisinger KR, Marks MW, Levine EA. Impact of Sentinel Lymph Node Biopsy on Immediate Breast Reconstruction after Mastectomy. Am Surg 2009. [DOI: 10.1177/000313480907500704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.
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Affiliation(s)
- Benjamin C. Wood
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lisa R. David
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - John H. Stewart
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Perry Shen
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kim R. Geisinger
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Malcolm W. Marks
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Edward A. Levine
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Rib-Sparing Internal Mammary Vessel Harvest for Microvascular Breast Reconstruction in 100 Consecutive Cases. Plast Reconstr Surg 2009; 123:1403-1407. [DOI: 10.1097/prs.0b013e3181a07249] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Risk factors for breast cancer-related upper extremity lymphedema: Is immediate autologous breast reconstruction one of them? Open Med (Wars) 2009. [DOI: 10.2478/s11536-009-0010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractBreast cancer related upper extremity lymphedema (BCRL) reduces the quality of life of those who have had surgery for breast cancer. The aim of this study is to evaluate the risk factors for BCRL and determine whether immediate autologous tissue breast reconstruction is one of them. A case control study was conducted comparing patients with BCRL (n=97) to surgically treated breast cancer patients without BCRL (control, n=126). The groups were matched for age, type of breast surgery and radiation therapy. Postoperative upper extremity infection, body mass index (BMI), occupation (level of hand-use), and immediate autologous tissue breast reconstruction were investigated as a risk factor of BCRL. Mastectomy was performed on 47.6 % (n=60) and 37.2% (n=36) of patients in the control and the BCRL groups, respectively. Eight patients (13.3%) had immediate autologous tissue breast reconstruction in the control mastectomy group. Six of 36 BCRL patients (16.7%) underwent mastectomy with immediate autologous tissue breast reconstruction. There was no significant difference between groups with respect to incidence or method of immediate reconstruction (p=0.65). Patient occupation (level of hand use) was found to be positively correlated to development of BCRL (p=0.0001). Upper extremity infection rate was 22.7% in the BCRL group and 4.0% in the controls (p=0.0001). The mean BMI in the control and BCRL groups 26.8 kg/m2 and 29.1kg/m2, respectively (p=0.003). In conclusion, in this study characteristics positively associated with development of BCRL included occupation, infection, and increased BMI. Immediate reconstruction of the breast was not found as a risk factor for BCRL. However larger studies are needed, to further evaluate the effect of breast reconstruction on BCRL.
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Aesthetic restoration of axillary contour deformity after lymph node dissection. J Plast Reconstr Aesthet Surg 2008; 61:231-2. [DOI: 10.1016/j.bjps.2007.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2007] [Accepted: 10/04/2007] [Indexed: 11/19/2022]
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