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von Glinski M, Holler N, Kümmel S, Reinisch M, Wallner C, Wagner JM, Dadras M, Sogorski A, Lehnhardt M, Behr B. Autologous Reconstruction After Failed Implant-Based Breast Reconstruction: A Comparative Multifactorial Outcome Analysis. Ann Plast Surg 2023; 91:42-47. [PMID: 37450860 DOI: 10.1097/sap.0000000000003599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Failure of an implant-based breast reconstruction often requires a change to an autologous procedure (salvage autologous breast reconstruction [Salv-ABR]). The aim of this study was to compare surgical and patient-reported outcomes of Salv-ABR to immediate or delayed-immediate ABR (I/DI-ABR), which has hardly been addressed in the existing literature. METHODS All patients undergoing Salv- or I/DI-ABR between January 2014 and December 2020 were asked to participate in this study. Complication rates, the aesthetic outcome (5-point Likert scale), and quality of life (EORTC QLQ-C30 and -BR23, Breast-Q, Center for Epidemiology Studies Depression Scale) were compared between both procedures. RESULTS Seventy patients participated in the study (Salv-ABR: n = 23; mean ± SD age, 53.5 ± 9.1 years; follow-up, 28.6 ± 18.5 month; I/DI-ABR: n = 45, mean ± SD age: 50.2 ± 7.3 years; follow-up, 32.8 ± 18.5 month). Main indication for Salv-ABR was a major capsular contracture (n = 14 [60.1%]). Early unplanned reoperation rates were significantly increased in the Salv-ABR (56.5% vs 14.9%; P < 0.01). Patients with I/DI-ABR showed a significantly improved overall aesthetic outcome (2.7 ± 0.9 vs 3.3 ± 0.7; P < 0.01) and scored significantly higher in several subscales of EORTC QLQ-C30/BR23 (Global Health Status, Role Functioning, Body Image; P < 0.05) and the Breast-Q (Psychosocial Well-being, Satisfaction with Breast; P < 0.05) compared with patients with Salv-ABR. CONCLUSIONS Salvage ABR is associated with a higher complication rate, compromised aesthetic outcome, and quality of life compared with I/DI-ABR. This should be considered and discussed with the patient when planning any kind of reconstructive breast surgery.
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Affiliation(s)
- Maxi von Glinski
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | - Nikla Holler
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | | | | | - Christoph Wallner
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | - Johannes Maximilian Wagner
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | - Mehran Dadras
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | - Alexander Sogorski
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | - Marcus Lehnhardt
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
| | - Björn Behr
- From the Department of Plastic and Hand Surgery, Burn Center, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum
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Kang JJ, Lee H, Park BH, Song YK, Park SE, Kim R, Lee KA. Efficacy of a 4-Week Nurse-Led Exercise Rehabilitation Program in Improving the Quality of Life in Women Receiving a Post-Mastectomy Reconstruction Using the Motiva Ergonomix TM Round SilkSurface. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:16. [PMID: 36612340 PMCID: PMC9819378 DOI: 10.3390/ijerph20010016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 06/17/2023]
Abstract
We assessed the efficacy of a 4-week nurse-led exercise rehabilitation (ER) program in improving the quality of life (QOL) of breast cancer survivors (BCS) receiving an implant-based breast reconstruction. The eligible patients were equally randomized to either of both groups: the intervention group (n = 30; a 4-week nurse-led ER program) and the control group (n = 30; a 4-week physical therapist-supervised one). Both after a 4-week ER program and at baseline, the patients were evaluated for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and Fatigue Severity Scale (FSS) scores. There was a significantly higher degree of increase in global health status/QOL scores, physical functioning scores, role functioning scores, and emotional functioning scores at 4 weeks from baseline in the intervention group as compared with the control group (p = 0.001). However, there was a significantly higher degree of decrease in fatigue scores, nausea/vomiting scores, pain scores, dyspnea scores, and FSS scores in the intervention group as compared with the control group (p = 0.001). In conclusion, our results indicate that a 4-week nurse-led ER program might be effective in the QOL in BCS receiving a post-mastectomy implant-based reconstruction using the Motiva ErgonomixTM Round SilkSurface.
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Affiliation(s)
- Jung Joong Kang
- Department of Physical Medicine and Rehabilitation, Booboo Medical Healthcare Hospital, Mokpo 58655, Republic of Korea
| | - Hyunho Lee
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea
| | - Bom Hui Park
- Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Yu Kwan Song
- Department of Plastic and Reconstructive Surgery, Chung Ju Mirae Hospital, Chungju 27361, Republic of Korea
| | - Soon Eun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea
| | - Robert Kim
- Department of Medical and Pharmaceutical Affairs, Doctor CONSULT, Seoul 06296, Republic of Korea
| | - Kyung Ah Lee
- Department of Plastic and Reconstructive Surgery, Inje University Haeundae Paik Hospital, 875 Haeun-daero, Busan 48108, Republic of Korea
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von Glinski M, Holler N, Kümmel S, Reinisch M, Wallner C, Wagner J, Dadras M, Sogorski A, Lehnhardt M, Behr B. Autologous vs. implant-based breast reconstruction after skin- and nipple-sparing mastectomy—A deeper insight considering surgical and patient-reported outcomes. Front Surg 2022; 9:903734. [PMID: 36132203 PMCID: PMC9483019 DOI: 10.3389/fsurg.2022.903734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAutologous (ABR) and implant-based breast reconstruction (IBR) represent the most common procedures after skin- and nipple-sparing mastectomy. This cross-sectional study is a comprehensive analysis of ABR and IBR considering surgical and patient-reported outcomes.Patients and methodsEligible patients underwent breast reconstruction (ABR and IBR) after skin- and nipple-sparing mastectomy between January 2014 and December 2020. Outcome parameters included quality of life (European Organisation for Research and Treatment of Cancer - EORTC - QLQ30, BR23, Breast-Q, CES-D), complication rates, aesthetic result, and breast sensitivity.Results108 patients participated in the study (IBR: n = 72, age 48.9 ± 9.9 years; ABR: n = 36, age: 46.6 ± 7.3 years). Mean follow-up was 27.1 ± 9.3 (IBR) and 34.9 ± 20.5 (ABR), respectively. IBR patients suffered significantly more often from major complications (30.6% vs. 8.3%; p = 0.01), while ABR patients underwent secondary procedures significantly more often to improve the aesthetic result (55.6% vs. 29.2%, p = 0.004). Unilateral reconstructions revealed superior aesthetic results in ABR (n.s.), while in bilateral reconstruction IBR tended to score higher (n.s.). Scar evaluation resulted in a better result of IBR in both categories (p < 0.01). Breast sensitivity was severely impaired in both groups. The Breast-Q revealed a significantly higher “patient satisfaction with breast” after ABR (p = 0.033), while the other QoL-tests and subscales showed no significant differences between the two procedures.ConclusionABR is associated with a higher patient satisfaction despite the high probability of secondary procedures to improve the aesthetic outcome, whereas IBR-patients suffer more often from major complications. Furthermore, the laterality of reconstruction should be included in the individual decision-making process.
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Affiliation(s)
- Maxi von Glinski
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
- Correspondence: Maxi von Glinski
| | - Nikla Holler
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Sherko Kümmel
- Department of Senology, Interdisciplinary Breast Cancer Center, Kliniken Essen-Mitte, Essen, Germany
- Clinic for Gynecology with Breast Center, Charité-Universitätsmedizin Berlin, Germany
| | - Mattea Reinisch
- Department of Senology, Interdisciplinary Breast Cancer Center, Kliniken Essen-Mitte, Essen, Germany
| | - Christoph Wallner
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Johannes Maximilian Wagner
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Mehran Dadras
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Alexander Sogorski
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Björn Behr
- Department of Plastic and Hand Surgery, Burn Center, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
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Shiraishi M, Sowa Y, Tsuge I, Kodama T, Inafuku N, Morimoto N. Long-Term Patient Satisfaction and Quality of Life Following Breast Reconstruction Using the BREAST-Q: A Prospective Cohort Study. Front Oncol 2022; 12:815498. [PMID: 35692774 PMCID: PMC9178786 DOI: 10.3389/fonc.2022.815498] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundBreast reconstruction is a promising surgical technique to improve health-related quality of life (HRQoL) in patients with breast cancer. However, the long-term risk factors associated with HRQoL after breast surgery are still unclear. Our aim was to evaluate breast satisfaction and HRQoL following breast reconstruction to identify clinical factors associated with each domain of BREAST-Q in the long-term.MethodsPatient-reported BREAST-Q outcomes were analyzed 1 and 5 years after breast reconstruction in a single-blinded, prospective study. Multiple regression analysis was performed to identify the risk and protective factors associated with BREAST-Q scores. These scores at 1 and 5 years were also compared across three types of operation: mastectomy only, tissue expander/implant (TE/Imp), and a deep inferior epigastric perforator (DIEP) flap.ResultsSurveys were completed by 141 subjects after 1 year and 131 subjects after 5 years. Compared to mastectomy only, breast reconstruction was significantly associated with greater “Satisfaction with breasts” (TE/Imp, p < 0.001; DIEP, p < 0.001) and “Psychosocial well-being” (TE/Imp, p < 0.001; DIEP, p < 0.001), higher body mass index (BMI) resulted in lower “Satisfaction with breasts” (p = 0.004), and a history of psychiatric or neurological medication was significantly associated with “Physical well-being” at 1-year postoperatively (p = 0.02). At 5 years, reconstructive procedures were significantly positively associated with greater “Satisfaction with breasts” (TE/Imp, p < 0.001; DIEP, p < 0.001) and “Psychosocial well-being” (TE/Imp, p = 0.03; DIEP, p < 0.001), and a bilateral procedure was a significant risk factor for lower “Psychosocial well-being” (p = 0.02).ConclusionsThe results of this study show that breast reconstruction improves “Satisfaction with Breasts” and “Psychosocial well-being” compared to mastectomy. Among all three types of operation, DIEP gave the best scores at 5 years postoperatively. Thus, autologous reconstruction is recommended for promotion of long-term HRQoL after breast surgery.
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Affiliation(s)
- Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, University Hospital Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Mie, Japan
| | - Yoshihiro Sowa
- Department of Plastic and Reconstructive Surgery, University Hospital Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- *Correspondence: Yoshihiro Sowa,
| | - Itaru Tsuge
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuya Kodama
- Department of Plastic and Reconstructive Surgery, Fukuchiyama City Hospital, Fukuchiyama, Japan
| | - Naoki Inafuku
- Department of Plastic and Reconstructive Surgery, University Hospital Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naoki Morimoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Huang JJ, Chuang EYH, Cheong DCF, Kim BS, Chang FCS, Kuo WL. Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: Feasibility and aesthetic results - Case series. Int J Surg 2021; 95:106143. [PMID: 34666195 DOI: 10.1016/j.ijsu.2021.106143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The application of robotic-assisted nipple-sparing mastectomy (R-NSM) has allowed mastectomy to be performed via a small incision. Breast reconstruction with free autologous tissue results in the most natural and long-lasting results, however, its application in R-NSM can be difficult via the small incision and haven't been explored in depth. The purpose of the study was to investigate the feasibility and aesthetic outcome of free perforator flap breast reconstruction via small lateral chest wall incision after R-NSM. MATERIALS AND METHODS A retrospective chart review was conducted to identify patients who received R-NSM and free perforator flap reconstruction as the study group and patients who received conventional nipple-sparing mastectomy (C-NSM) and free perforator flap reconstruction as the control group from January 2018 to August 2020 by single reconstructive surgeon. Patient demographic data, complications from both mastectomy and reconstruction, status of resection margin and oncological outcome were reviewed. Aesthetic outcome was evaluated by 9 plastic surgeons. RESULTS A total of 63 patients were included of which 22 (34.9%) received R-NSM and 41 (65.1%) received C-NSM. Their demographic data, reconstruction flaps, overall complication rate and follow up time were similar. Unlike C-NSM, majority of the R-NSM groups used the thoracodorsal or lateral thoracic vessels as the recipient vessels. Patients in the R-NSM group has smaller scar and better aesthetic outcome in the symmetry of breast inframammary fold, scar location and visibility, and overall aesthetic outcome. CONCLUSION Although with difficulty in microvascular anastomosis and flap inset and shaping, R-NSM with perforator flap reconstruction presented with equal surgical and oncological safety with C-NSM and even better aesthetic results.
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Affiliation(s)
- Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan College of Medicine, Chang Gung University, Taoyuan, Taiwan Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Department of General Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Switzerland Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Pietruski P, Noszczyk B, Paskal AM, Paskal W, Paluch Ł, Jaworowski J. The Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study. Aesthet Surg J 2020; 40:850-861. [PMID: 31562524 DOI: 10.1093/asj/sjz252] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Little is known about breast cancer survivors' perception of breast attractiveness. A better understanding of this subjective concept could contribute to the improvement of patient-reported outcomes after reconstructive surgeries and facilitate the development of new methods for assessing breast reconstruction outcomes. OBJECTIVES The aim of this eye-tracking (ET)-based study was to verify whether mastectomy altered women's visual perception of breast aesthetics and symmetry. METHODS A group of 30 women after unilateral mastectomy and 30 healthy controls evaluated the aesthetics and symmetry of various types of female breasts displayed as highly standardized digital images. Gaze patterns of women from the study groups were recorded using an ET system and subjected to a comparative analysis. RESULTS Regardless of the study group, the longest fixation duration and the highest fixation number were found in the nipple-areola complex. This area was also the most common region of the initial fixation. Several significant between-group differences were identified; the gaze patterns of women after mastectomy were generally characterized by longer fixation times for the inframammary fold, lower pole, and upper half of the breast. CONCLUSIONS Mastectomy might affect women's visual perception patterns during the evaluation of breast aesthetics and symmetry. ET data might improve our understanding of breast attractiveness and constitute the basis for a new reliable method for the evaluation of outcomes of reconstructive breast surgeries.
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Affiliation(s)
- Piotr Pietruski
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Prof. W. Orlowski Memorial Hospital, Warsaw, Poland
| | - Bartłomiej Noszczyk
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Prof. W. Orlowski Memorial Hospital, Warsaw, Poland
| | - Adriana M Paskal
- Department of Research Methodology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Wiktor Paskal
- Department of Research Methodology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Paluch
- Department of Radiology, Medical Centre of Postgraduate Education, Gruca Orthopaedic and Trauma Teaching Hospital, Otwock, Poland
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Yang CQ, Ji F, Gao HF, Zhang LL, Yang M, Zhu T, Chen MY, Li JQ, Wang K. The Role of Sharp Dissection in Nipple-Sparing Mastectomy: A Safe Procedure with No Necrosis of the Nipple-Areolar Complex. Cancer Manag Res 2019; 11:10223-10228. [PMID: 31824192 PMCID: PMC6900313 DOI: 10.2147/cmar.s230787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/20/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nipple-sparing mastectomy (NSM) is becoming increasingly accepted as a treatment for breast disease; however, nipple-areolar complex (NAC) necrosis, a frequent severe postoperative complication, inhibits the popularity of this procedure. This study reports the technical aspects and short-term postoperative outcomes of NSM. Methods A single-center, retrospective review of 110 patients treated with NSM at our institution from November 2015 to September 2018 was performed. The primary outcome was the incidence of NAC necrosis. Results A total of 130 NSMs performed on 110 patients were included in our study. Median patient age was 42 years. We performed a sharp dissection by using a scalpel, raising 3–5 mm thick flaps, and continuing onto the undersurface of the NAC. None of the 110 patients appeared to have NAC necrosis or mastectomy skin flap necrosis. However, discoloration or ischemia of the NAC with eschar formation presented between postoperative days 3 and 7 in six nipples; four nipples were ischemic, and two were discolored. No infection was detected in any of the 110 patients. All NACs were intact after an average follow-up of 30 months, and no local or systemic recurrence was detected in those breast cancer cases. Conclusion NSM can be safely performed in properly selected patients. Nipple necrosis was avoided using a special surgical technique, and other complications occurred at an acceptable rate.
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Affiliation(s)
- Ci-Qiu Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Fei Ji
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Hong-Fei Gao
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Liu-Lu Zhang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Mei Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Teng Zhu
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Min-Yi Chen
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jie-Qing Li
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Kun Wang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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Qing L, Li X, Wu P, Zhou Z, Yu F, Tang J. Customized reconstruction of complex soft-tissue defect in the hand and forearm with individual design of chain-linked bilateral anterolateral thigh perforator flaps. J Plast Reconstr Aesthet Surg 2019; 72:1909-1916. [PMID: 31564579 DOI: 10.1016/j.bjps.2019.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/16/2019] [Accepted: 08/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Complex soft-tissue defects of upper extremities still have a high rate of amputation, as the reconstruction of complex soft-tissue defects is always difficult even with the largest conventional free flap. The anterolateral thigh perforator (ALTP) flap is one of the most popular procedures used for the coverage of complex soft-tissue defects of extremities. However, problems associated with donor-site morbidity and inability to repair complex soft-tissue defects in a one-stage procedure persist. The purpose of this study was to present a novel design of using chain-linked bilateral ALTP flap and its various designs for customized reconstruction of complex soft-tissue defects in the hands and forearms. METHODS From June 2009 to June 2017, we retrospectively analyzed 15 patients with complex soft-tissue defects in the hands and forearms. All patients in this series underwent extremity reconstruction using the chain-linked bilateral ALTP flaps. Three different types of chain-linked bilateral ALTP flaps were created in this study based on wound characteristics and the maximum available skin paddle size at all donor sites. RESULTS The chain-linked bilateral ALTP flaps were successfully harvested for the reconstruction of complex soft-tissue defects in the hands and forearms. Among them, ten cases were repaired with chain-linked bipaddle ALTP flaps, two cases were treated with chain-linked tripaddle ALTP flaps, and the remaining three cases were used with chain-linked multi-lobed ALTP chimeric flaps. The sizes of the skin paddles ranged from 11 cm × 7 cm to 42 cm × 8 cm. The areas of the total flaps ranged from 245 cm2 to 650 cm2 (mean 419.6 cm2). Only one case required re-exploration because of the venous congestion. The donor sites were closed directly. The mean follow-up time was 16.4 months. Most cases showed satisfactory contour. CONCLUSION The chain-linked bilateral ALTP flap is a reliable option for one-stage reconstruction of complex soft-tissue defects in the hands and forearms with limited donor-site morbidity. It also provides various flap designs, which allow for more individualized treatment approaches.
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Affiliation(s)
- Liming Qing
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China; Department of Neurosurgery, Maryland University of Medicine School, Baltimore, United States
| | - Xiaoxiao Li
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China; Department of Neurosurgery, Maryland University of Medicine School, Baltimore, United States
| | - Panfeng Wu
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Zhengbing Zhou
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Fang Yu
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Juyu Tang
- Department of orthopedic, Xiangya Hospital of Central South University, Changsha 410008, China.
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Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap. Arch Plast Surg 2019; 46:135-139. [PMID: 30934177 PMCID: PMC6446034 DOI: 10.5999/aps.2017.01690] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 10/22/2018] [Indexed: 11/08/2022] Open
Abstract
Background In immediate breast reconstruction using an extended latissimus dorsi musculocutaneous (eLDMC) flap, the volume of the flap decreases, which causes a secondary deformity of the breast shape. Since little research has investigated this decrease in muscle volume, the authors conducted an objective study to characterize the decrease in muscle volume after breast reconstruction using an eLDMC flap. Methods Research was conducted from October 2011 to November 2016. The subjects included 23 patients who underwent mastectomy due to breast cancer, received immediate reconstruction using an eLDMC flap without any adjuvant chemotherapy or radiotherapy, and received a computed tomography (CT) scan from days 7 to 10 after surgery and 6 to 8 months postoperatively. In 10 patients, an additional CT scan was conducted 18 months postoperatively. Axial CT scans were utilized to measure the volumetric change of the latissimus dorsi muscle during the follow-up period. Results In the 23 patients, an average decrease of 54.5% was observed in the latissimus dorsi muscle volume between the images obtained immediately postoperatively and the scans obtained 6 to 8 months after surgery. Ten patients showed an average additional decrease of 11.9% from 6–8 months to 18 months after surgery. Conclusions We studied changes in the volume of the latissimus dorsi muscle after surgery using an eLDMC flap performed after a mastectomy without adjuvant chemotherapy or radiotherapy. In this study, we found that immediate breast reconstruction using a latissimus dorsi muscle flap led to a decrease in muscle volume of up to 50%.
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Grieco MP, Simonacci F, Bertozzi N, Grignaffini E, Raposio E. Breast reconstruction with breast implants. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 89:457-462. [PMID: 30657111 PMCID: PMC6502088 DOI: 10.23750/abm.v89i4.5748] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Breast cancer is the most common noncutaneous malignancy among women worldwide. After a breast cancer removal procedure, women are asked to decide about breast reconstruction, mainly to improve their life quality, and they can choose from among many options. Broadly, there are two different types of breast reconstruction procedures: prosthetic implant-based reconstruction and autologous tissue-based reconstruction. METHODS Implant-breast reconstruction is a minimally invasive procedure compared with autologous breast reconstruction. It is associated with fewer short- and long-term complications. RESULTS The ideal candidates for implant-based reconstruction are patients with non-redundant soft tissue coverage, who desire a moderate sized non-ptotic breast and have not been previously irradiated. CONCLUSION The state of the art for implant-breast reconstruction is briefly described in this article.
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Affiliation(s)
- Michele Pio Grieco
- Department of Surgical Sciences, Plastic Surgery Division, University of Parma, Parma, Italy Cutaneous, Regenerative, Mininvasive and Plastic Surgery Unit, Parma University Hospital, Italy.
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Ho OA, Lin YL, Pappalardo M, Cheng MH. Nipple-sparing mastectomy and breast reconstruction with a deep inferior epigastric perforator flap using thoracodorsal recipient vessels and a low lateral incision. J Surg Oncol 2018; 118:621-629. [PMID: 30212598 DOI: 10.1002/jso.25204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/23/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy poses challenges in providing esthetically-pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple-sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites. METHODS Between 2010 and 2016, 79 patients who underwent nipple-sparing mastectomy with autologous breast reconstruction using thoracodorsal (TD) vessels in 30 cases or internal mammary (IM) vessels in 49 cases were investigated. Demographics, intraoperative findings, complications, and quality of life using Breast-Q questionnaire were compared between two groups. RESULTS All flap survived. There was no statistical difference in age, BMI, ischemia time, and flap-used percentage. The TD artery had a statistically smaller diameter 1.8 ± 0.4 mm than the IM artery 2.7 ± 0.43 mm (p = 0.02). At a mean follow-up of 44.4 ± 35.2 months, there was no statistical difference in total complication rates between TD and IM groups (23.3% and 36.7%, respectively, p > 0.05). The "psychosocial well-being" of Breast-Q in TD group 83.9 ± 14.6 was statistically greater than IM group 72.8 ± 17.6 (p = 0.04). CONCLUSIONS Nipple-sparing mastectomy with immediate breast reconstruction using TD vessels with a low lateral scar is a safe procedure that provides an inconspicuous scar with better cosmesis and minimal complication rate.
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Affiliation(s)
- Olivia A Ho
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Yi-Ling Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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12
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Radovanovic Z, Ranisavljevic M, Radovanovic D, Vicko F, Ivkovic-Kapicl T, Solajic N. Nipple-Sparing Mastectomy with Primary Implant Reconstruction: Surgical and Oncological Outcome of 435 Breast Cancer Patients. Breast Care (Basel) 2018; 13:373-378. [PMID: 30498425 DOI: 10.1159/000489317] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background This study aimed to examine the incidence of surgical complications associated with nipple-sparing mastectomy (NSM) with primary implant reconstruction, analyze risk factors for early and late surgical complications of NSM, and determine the incidence of local recurrences and the safety of sparing the nipple-areola complex (NAC). Methods This retrospective cohort study included 435 patients with 441 NSM procedures over a period of 9 years (2004-2012). All surgical complications and the oncological outcome were recorded during follow-up. Results The most common early surgical complication was skin flap ischemia/necrosis (26 patients, 5.9%). Prosthesis explantation due to complications was carried out in 11 (2.5%) cases. Neoadjuvant chemotherapy, implant size >500 ml, diabetes mellitus, body mass index > 25 kg/m2, and incisions other than lateral were risk factors for early complications (p < 0.001). The NAC excision rate was 5.4% (24 cases) due to confirmed presence of cancer cells in the subareolar tissue. Capsular contracture as a late complication occurred in 33 (7.48%) cases. Local relapse occurred in 32 (7.3%) patients. Distant metastases were diagnosed in 68 (15.6%) patients, and 53 (12.2%) patients died during the follow-up period. Conclusions NSM with immediate implant reconstruction has an acceptable morbidity rate and is an oncologically and surgically appropriate treatment for most women requiring mastectomy.
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Affiliation(s)
- Zoran Radovanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Milan Ranisavljevic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Dragana Radovanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Ferenc Vicko
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Tatjana Ivkovic-Kapicl
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Nenad Solajic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
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13
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Roh TS, Kim JY, Jung BK, Jeong J, Ahn SG, Kim YS. Comparison of Outcomes between Direct-to-Implant Breast Reconstruction Following Nipple-Sparing Mastectomy through Inframammary Fold Incision versus Noninframammary Fold Incision. J Breast Cancer 2018; 21:213-221. [PMID: 29963118 PMCID: PMC6015980 DOI: 10.4048/jbc.2018.21.2.213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/17/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose In properly selected patients with breast cancer, nipple-sparing mastectomy (NSM) is generally considered safe by oncologic standards. We examined two groups of patients who underwent direct-to-implant (DTI) reconstruction after NSM, comparing complications encountered, revision rates, and aesthetic outcomes. The patients were stratified based on type of surgical incision and assigned to inframammary fold (IMF) and non-IMF groups. Methods We investigated 141 patients (145 breasts) subjected to NSM and immediate DTI reconstruction between 2013 and 2016. A total of 62 breasts (in 58 patients) were surgically removed via IMF incisions, with the other 83 breasts (in 83 patients) removed by non-IMF means. Results Complications associated with IMF (n=62) and non-IMF (n=83) incisions were as follows: skin necrosis (IMF, 9; non-IMF, 18); hematoma (IMF, 3; non-IMF, 4); seroma (IMF, 8; non-IMF, 4); mild capsular contracture (IMF, 4; non-IMF, 7); and tumor recurrence (IMF, 2; non-IMF, 8). Surgical revisions were counted as duplicates (IMF, 18; non-IMF, 38). Aesthetic outcomes following IMF incisions were rated as very good (44.2%), good (23.1%), fair (23.1%), or poor (9.6%). Conclusion IMF incision enables complete preservation of the nipple-areolar complex, yielding superior aesthetic results in immediate DTI breast reconstruction after NSM. The nature of incision used had no significant impact on postoperative complications or reoperation rates and had comparable oncologic safety to that of non-IMF incisions. IMF incisions produced the least visible scarring and did not affect breast shape. Most patients were satisfied with the aesthetic outcomes.
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Affiliation(s)
- Tai Suk Roh
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Yoon Kim
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Bok Ki Jung
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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14
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Marquez MDLP, Fernandez-Riera R, Cardona HV, Flores JMR. Immediate implant replacement with DIEP flap: a single-stage salvage option in failed implant-based breast reconstruction. World J Surg Oncol 2018; 16:80. [PMID: 29665804 PMCID: PMC5905049 DOI: 10.1186/s12957-018-1387-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/10/2018] [Indexed: 11/23/2022] Open
Abstract
Background Implant-based immediate breast reconstruction after skin-sparing mastectomy has shown a significant improvement in patients’ quality of life, making the procedure steadily more popular year after year. However, this technique has a high morbidity rate, including skin necrosis and implant exposure. Methods A retrospective review of a prospectively held database for autologous breast reconstruction in our institution of the last 5 years found eight cases with exposed implants after nipple-sparing mastectomy and immediate reconstruction. A single-stage procedure consisting on implant removal and immediate replacement with a deepithelialized DIEP flap was performed in all cases (10 DIEP flaps). Results All flaps were successful. Patients’ mean age was 45 years old. Three patients developed seroma (5, 7, and 14 days after surgery, respectively). No infections were detected in up to 24 months of follow-up. Conclusions Nipple-sparing mastectomy with immediate implant-based reconstruction is considered oncologically safe. However, it has a high rate of complications that could require implant removal. Immediate free flap reconstruction is a feasible and safe option to replace the missing volume with low risk of complications that result in a soft and natural-shaped breast.
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Affiliation(s)
- Miguel De La Parra Marquez
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico.
| | - Ricardo Fernandez-Riera
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Ruben Leñero, Plan de San Luis esq Salvador Díaz Mirón SN, Col. Santo Tomás. Deleg. Miguel Hidalgo. Cp. 11340. CDMX, Mexico City, Mexico
| | - Hector Vela Cardona
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico
| | - Jesus María Rangel Flores
- Division of Plastic and Reconstructive Surgery, Mexican Institute of Social Security (IMSS), No. 21 Pino Suárez y 15 de Mayo, Av. Hidalgo 2480 pte, col. Obispado. C.p.64060. Cons. 212, Monterrey Nuevo León, Mexico
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15
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The Aesthetic Items Scale: A Tool for the Evaluation of Aesthetic Outcome after Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1254. [PMID: 28458968 PMCID: PMC5404439 DOI: 10.1097/gox.0000000000001254] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/10/2017] [Indexed: 11/28/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Valid tools to assess aesthetic outcomes after breast reconstructive surgery are scarce. Previously a professional aesthetic assessment scale was introduced, the Aesthetic Items Scale (AIS). We aim to determine if this method is a valid and reliable tool to assess aesthetic outcome after breast reconstructive surgery. Methods: The study population was consenting women who underwent prophylactic mastectomy with subsequent implant-based breast reconstruction. The aesthetic outcome with regard to breast volume, shape, symmetry, scars, and nipple areola complex was rated on a 5-point scale using standardized photographs to give a summed total score. Photographs were evaluated by the patient, 5 plastic surgeons, and 3 mammography nurses. An overall rating of aesthetic outcome on a 1–10 scale was given separately. We determined the intraclass correlation coefficient and assessed interobserver agreement. To assess validity, we calculated the correlation between total score and overall rating of aesthetic outcome. Results: Interobserver reliability was highest between plastic surgeons for the subitem and overall scores and ranged between 0.56 and 0.82. The summed score of the AIS correlates strongly with the overall rating in professionals but not in patients. Conclusions: The AIS is a valid and reliable method for evaluating aesthetic outcome of breast reconstruction by plastic surgeons. The results indicate that patients judge aesthetic outcome differently, taking into account factors that are not represented in the AIS. Professionals can use this method to evaluate surgical results, but other measurements are needed to map satisfaction of the patient with her breasts.
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16
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Satteson ES, Brown BJ, Nahabedian MY. Nipple-areolar complex reconstruction and patient satisfaction: a systematic review and meta-analysis. Gland Surg 2017; 6:4-13. [PMID: 28210547 DOI: 10.21037/gs.2016.08.01] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Nipple-areola complex (NAC) reconstruction transforms a mound of soft tissue into a breast and often marks the final stage of breast reconstruction after mastectomy. METHODS A systematic review and meta-analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Articles were classified based on the nipple reconstructive technique-either composite nipple sharing or local flap with nipple-sparing mastectomy (NSM) used as a control. A standardized "Satisfaction Score" (SS) for "nipple appearance" and "nipple sensation" was calculated for each technique. A Fisher's exact test was used to compare the SS with local flap reconstruction with NSM. RESULTS Twenty-three studies met the systematic review inclusion criteria. Nine NSM articles were identified with patient satisfaction data from 473 patients. The weighted average SS for NSM was 80.5%. Fourteen local flap technique articles were identified with satisfaction data from 984 patients and a weighted average SS of 73.9%. This was a statistically significant difference (P=0.0079). C-V and badge local flap techniques were associated with the highest SS, 92.6% and 90.5%, respectively. C-V and modified C-V flap technique was associated with a higher SS when compared to those using one or more other flap techniques (P=0.0001). CONCLUSIONS While patient satisfaction with nipple reconstruction is high regardless of technique, it is higher with NSM. When NSM is not an option, local flap reconstruction with a C-V or modified C-V flap may be associated with higher satisfaction than alternative local flap techniques.
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Affiliation(s)
- Ellen S Satteson
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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17
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The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures. Arch Plast Surg 2016; 43:328-38. [PMID: 27462565 PMCID: PMC4959975 DOI: 10.5999/aps.2016.43.4.328] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 05/18/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4–156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.
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18
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Abstract
INTRODUCTION Besides the diffusion of breast reconstructive techniques, several "conservative" approaches in mastectomy have been developed, in order to perform an immediate reconstruction with better aesthetic results: the skin-sparing mastectomy (SSM), the nipple-areola complex (NAC)-sparing mastectomy (NSM) and the skin-reducing mastectomy (SRM). During the last decade, SSMs and NSMs have gained widespread acceptance and are currently considered standard treatment for early breast cancer. We would like to investigate the evidence behind this radical shift towards conservative mastectomies, where there has been a renewed interest worldwide. METHODS We reviewed English literature by consulting the following databases: Medline, Embase, Cochrane Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal and Clinicaltrials.gov. The objective is to include any randomized controlled trial (RCT) comparing a "conservative mastectomy" technique to breast conservative surgery or modified radical mastectomy (MRM) for the treatment of early-stage breast cancer. In the absence of randomized trials, we took into account prospective cohorts and retrospective series for a narrative description of available evidence. RESULTS Our review included 58 studies [19 prospective cohorts (34%) and 39 retrospective series (66%)] considering NSM and immediate reconstruction and ten studies [1 prospective cohort (10%) and 9 (90%) retrospective series] considering SSM and immediate reconstruction. In the NSM group, 29 studies reported data about complication rates and 42 studies presented data on NAC partial or complete necrosis. In the NSM group 45 studies and all the studies in the SSM group presented data on local and NAC recurrence. CONCLUSIONS In order to achieve higher levels of evidence, RCTs comparing conservative mastectomies to traditional mastectomy and breast conservative surgery would be desirable. However we can conclude that conservative mastectomies offer the psychological advantages of good cosmetics and maintenance of woman body image without compromising the oncological safety of mastectomy.
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Affiliation(s)
- Nicola Rocco
- 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131 Naples, Italy ; 2 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122 Milano, Italy
| | - Giuseppe Catanuto
- 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131 Naples, Italy ; 2 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122 Milano, Italy
| | - Maurizio Bruno Nava
- 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131 Naples, Italy ; 2 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122 Milano, Italy
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19
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Gravvanis A, Samouris G, Galani E, Tsoutsos D. Dual plane diep flap inset: Optimizing esthetic outcome in delayed autologous breast reconstruction. Microsurgery 2015. [DOI: 10.1002/micr.22458] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andreas Gravvanis
- Department of Plastic Surgery-Microsurgery and Burn Center J. Ioannovich; General Hospital of Athens G.Gennimatas; Athens Greece
| | - George Samouris
- Department of Plastic Surgery-Microsurgery and Burn Center J. Ioannovich; General Hospital of Athens G.Gennimatas; Athens Greece
| | - Eleni Galani
- Department of Plastic Surgery-Microsurgery and Burn Center J. Ioannovich; General Hospital of Athens G.Gennimatas; Athens Greece
| | - Dimosthenis Tsoutsos
- Department of Plastic Surgery-Microsurgery and Burn Center J. Ioannovich; General Hospital of Athens G.Gennimatas; Athens Greece
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20
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Maass SWMC, Bagher S, Hofer SOP, Baxter NN, Zhong T. Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals. Ann Surg Oncol 2015; 22:4305-16. [PMID: 25691279 DOI: 10.1245/s10434-015-4434-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Saskia W M C Maass
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - Shaghayegh Bagher
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - Stefan O P Hofer
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nancy N Baxter
- Departments of Surgery and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Toni Zhong
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada. .,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
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21
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The use of real-time digital video in the assessment of post-operative outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:1357-63. [PMID: 24923524 DOI: 10.1016/j.bjps.2014.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 01/20/2014] [Accepted: 05/20/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Outcome measures of breast reconstruction have used panel assessment of photographs. This provides limited information to the assessor as these images are static.. The aim of this study was to assess whether the use of digital video was a valid assessment tool and to compare its use against photography. METHODS 35 patients post-reconstruction underwent photography, digital video capture and completed Breast Cancer Treatment Outcomes Scale (BCTOS) questionnaires. The photographs/video clips were randomised and shown to a 21 member panel. Opinions on aesthetic aspects of the reconstruction were assessed using the BCTOS and Harris scale. Panel inter-rater agreement and patient-panel correlation was assessed using Kendall's Coefficient of Concordance and Spearman's rank correlation tests respectively. RESULTS There was a "moderate" degree of inter-rater agreement amongst panel members in all categories. Greater agreement occurred using video footage to assess overall cosmesis (0.548 vs 0.507) and shape (0.505 vs 0.486). Video showed a greater degree of correlation with patient self-assessment scores in comparison to photography (0.311 vs 0.281). CONCLUSION Video footage coupled with panel assessment is a valid method of assessing post-operative outcomes of breast reconstruction and appears superior to still photographs in terms of inter-rater agreement and correlation with patient self-assessment.
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22
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Methylene blue dye-induced skin necrosis in immediate breast reconstruction: evaluation and management. Arch Plast Surg 2014; 41:258-63. [PMID: 24883277 PMCID: PMC4037772 DOI: 10.5999/aps.2014.41.3.258] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/22/2013] [Accepted: 09/09/2013] [Indexed: 11/18/2022] Open
Abstract
Background For early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported. Methods Immediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation. Results Six cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction. Conclusions The complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.
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23
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Santanelli Di Pompeo F, Longo B, Sorotos M, Pagnoni M, Laporta R. The axillary versus internal mammary recipient vessel sites for breast reconstruction with diep flaps: A retrospective study of 256 consecutive cases. Microsurgery 2014; 35:34-8. [DOI: 10.1002/micr.22266] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Fabio Santanelli Di Pompeo
- Plastic Surgery Unit; Sant'Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome; Rome Italy
| | - Benedetto Longo
- Plastic Surgery Unit; Sant'Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome; Rome Italy
| | - Michail Sorotos
- Plastic Surgery Unit; Sant'Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome; Rome Italy
| | - Marco Pagnoni
- Plastic Surgery Unit; Sant'Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome; Rome Italy
| | - Rosaria Laporta
- Plastic Surgery Unit; Sant'Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome; Rome Italy
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Cohen M, Bannier M, Lambaudie E, Chéreau-Ewald E, Buttarelli M, Jauffret C, Houvenaeghel G. Conservation de la plaque aréolo-mamelonnaire en cas de mastectomie. ACTA ACUST UNITED AC 2014; 42:246-51. [DOI: 10.1016/j.gyobfe.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Differentiate among the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent in different reconstructive breast procedures. 5. Summarize the long-term objective and subjective implications of surgery. SUMMARY This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.
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Abstract
BACKGROUND Different approaches have been advocated for performing nipple-areola-sparing mastectomy. The inframammary approach has been viewed as having limited applications, particularly in large breasts. The authors review their experience with nipple-areola-sparing mastectomy using the inframammary approach for different breast sizes. METHODS Between 2005 and 2012, 118 nipple-areola-sparing mastectomies with staged implant-based reconstruction were performed in 80 consecutive patients. Patients with different breast sizes underwent inframammary nipple-areola-sparing mastectomy, except those patients who had very large breasts or those who requested a breast lift. Oncologic data related to tumor size, selection criteria, and recurrences are presented. All nipple-areola-sparing mastectomies and reconstructions were performed by the same surgeons (J.K.H. and A.H.S), who operated as a team in performing the mastectomies. RESULTS Patients were followed up from 6 to 97 months (mean, 33.5 months). There were four recurrences (5 percent), three of which were attributed to the biological behavior of the tumor. The aesthetic outcomes of the reconstructions were analyzed based on nipple location, breast contour, and symmetry: 35 patients (44 percent) had a very good result, 28 (35 percent) had a good result, nine (11 percent) had a fair result, and eight (10 percent) had a poor result. Risk factors and complications affecting the final aesthetic outcome are discussed. CONCLUSIONS The inframammary approach for nipple-areola-sparing mastectomy is the authors' procedure of choice for small, medium, and large breasts. The team approach to the mastectomy facilitates the procedure, reduces skin-related complications, and results in a better aesthetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg 2014; 132:1043-1054. [PMID: 23924650 DOI: 10.1097/prs.0b013e3182a48b8a] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy is a controversial option for breast cancer treatment due to locoregional recurrence and distant metastasis. In addition to these oncologic factors, technical factors such as ideal incision type or reconstructive options are also debatable. This systematic review examines current trends with nipple-sparing mastectomy, including selection criteria, locoregional and distant metastasis rates, incision choice, and reconstructive options. METHODS Systematic electronic searches were performed in the PubMed and Ovid databases using search terms for studies reporting outcomes following nipple-sparing mastectomy and all forms of reconstruction. Studies between 1970 and 2013 were reviewed. Pooled descriptive statistics with separate analyses for incision type and reconstructive method were performed. RESULTS Forty-eight studies met inclusion criteria, yielding 6615 nipple-sparing mastectomies for analysis. The overall pooled complication rate was 22 percent, the nipple necrosis rate was 7 percent, the locoregional recurrence rate was 1.8 percent, and the distant metastasis rate was 2.2 percent. Comparing combined patient cohorts for two-stage expander to implant, one-stage direct to implant, and autologous reconstruction demonstrated overall complication rates of 52.8, 16.7, and 23.7 percent and nipple necrosis rates of 4.5, 4.1, and 17.3 percent, respectively. Incision types were divided into five categories: radial, periareolar/circumareolar, inframammary, mastopexy, and transareolar, with nipple necrosis rates of 8.83, 17.81, 9.09, 4.76, and 81.82 percent, respectively CONCLUSIONS Nipple-sparing mastectomy appears to be an oncologically safe option for properly selected patients, with low rates of locoregional and distant metastasis. Overall complication and nipple necrosis rates are affected by incision location and reconstruction method. Randomized controlled trials are warranted to determine best incision and reconstructive methods. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Stolier A, Stone JC, Moroz K, Hanemann CW, McNabb L, Jones SD, Lacey M. A comparison of clinical and pathologic assessments for the prediction of occult nipple involvement in nipple-sparing mastectomies. Ann Surg Oncol 2012; 20:128-32. [PMID: 23010730 DOI: 10.1245/s10434-012-2511-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy. METHODS The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted. RESULTS Using clinical criteria alone, the false negative rate was 53.8% and a false positive rate of 44.4%. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7% but the false positive rate remained at 44.4%. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8%. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive. CONCLUSIONS This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.
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Affiliation(s)
- Alan Stolier
- Department of Surgery, Tulane University Medical Center, 1717 St. Charles Ave, New Orleans, LA, USA.
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Veronesi U, Stafyla V, Petit JY, Veronesi P. Conservative mastectomy: extending the idea of breast conservation. Lancet Oncol 2012; 13:e311-7. [DOI: 10.1016/s1470-2045(12)70133-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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The Thoracodorsal Artery and Vein as Recipient Vessels for Microsurgical Breast Reconstruction. Ann Plast Surg 2012; 68:542-3. [DOI: 10.1097/sap.0b013e318231add4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Nipple-sparing mastectomy (NSM) is a surgical protocol designed to reduce the disabling psychological effects of radical or skin-sparing mastectomy. The preservation of the nipple-areola complex produces a more-natural result of the breast reconstruction, but this preservation is suspected of increasing tumor local recurrence. To reduce this risk, different approaches have been proposed: restrict the inclusion criteria and/or add localized radiation therapy. The local recurrence rate in recent series of patients receiving NSM is comparable with the local recurrence rate in modified radical or skin-sparing mastectomies. Today, the quality of the subcutaneous mastectomy technique allows for a more radical glandular removal, especially in the retroareolar area; therefore, local recurrence is observed in 3-6% of patients at 5 years, consistent with traditional mastectomy.
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Mátrai Z, Gulyás G, Tóth L, Sávolt Á, Kunos C, Pesthy P, Bartal A, Kásler M. Role of nipple sparing mastectomy in modern breast surgery. Orv Hetil 2011; 152:1233-49. [DOI: 10.1556/oh.2011.29156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recently an increasing number of reports of clinical experience have been published on nipple-sparing mastectomy. By the preservation of uninvolved skin and the nipple areola complex, this surgical technique greatly facilitates immediate reconstruction and optimal aesthetic outcome. However, the procedure raises serious oncologic concerns regarding the risk of an occult or a newly formed primary tumor due to parenchyma left behind in the nipple and the retroareola. Despite the ever increasing popularity of the method, there is still no evidence based confirmation to it. According to data from scientific literature on nipple-sparing mastectomy, there is no straightforward consequence to be drawn on oncologic safety; therefore the procedure is not generally considered to be alternative to standard mastectomy. In the indication of risk reduction, justification of the intervention seems to be well supported, and is expected to foster a greater rate of acceptance of surgical prophylaxis in patients with higher risk diseases. The procedure should be carried out possibly in the framework of clinical trials, in well selected patients with suitable preoperative and postoperative examinations, applying precise techniques and adequate patient education, according to international guidelines. Further long-term results are needed to form a substantive expert opinion. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language. Orv. Hetil., 2011, 152, 1233–1249.
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Affiliation(s)
- Zoltán Mátrai
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Gusztáv Gulyás
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
| | - László Tóth
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Ákos Sávolt
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Csaba Kunos
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
| | - Pál Pesthy
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
| | | | - Miklós Kásler
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
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Patient satisfaction in unilateral and bilateral breast reconstruction [outcomes article]. Plast Reconstr Surg 2011; 127:1417-1424. [PMID: 21460649 DOI: 10.1097/prs.0b013e318208d12a] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The goal of reconstruction after mastectomy is to provide a long-term and symmetric reconstruction. Providing symmetry entails different decision making when faced with a unilateral or bilateral reconstruction. In unilateral reconstruction, the goal is to match the contralateral breast; however, in bilateral reconstruction, symmetry between the reconstructed breasts is more important. The purpose of this study was to examine patient satisfaction between unilateral and bilateral reconstruction. METHODS All women at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected. A survey was administered examining general and aesthetic satisfaction. Patients with unilateral reconstruction were identified and compared with patients with bilateral reconstruction. Additional analysis was performed based on the type of reconstruction, including autologous, autologous with implant, and tissue expander/implant-based reconstruction. RESULTS Overall, 702 women underwent 910 breast reconstructions (494 unilateral, 416 bilateral). Patients in the bilateral reconstruction group were more likely to have prophylactic mastectomy and immediate reconstruction. Complication rates were similar between unilateral and bilateral reconstruction. Patient satisfaction was highest in unilateral patients with autologous compared with implant reconstruction (general satisfaction, 73.9 versus 40.9 percent, p < 0.0001; aesthetic satisfaction, 72.3 versus 43.2 percent, p < 0.0001). Bilateral reconstruction had similar general and aesthetic satisfaction scores across autologous, autologous with implant, and implant-based reconstruction. CONCLUSIONS Patients undergoing unilateral reconstruction have the highest satisfaction with autologous reconstruction. As symmetry between reconstructed breasts is essential for patient satisfaction in bilateral reconstruction, it is important to use the same type of reconstruction, whether autologous or implant-based.
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Prosthetic Breast Reconstruction After Implant-Sparing Mastectomy in Patients With Submuscular Implants. Ann Plast Surg 2011; 66:546-50. [DOI: 10.1097/sap.0b013e31820b3ad7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Potter S, Harcourt D, Cawthorn S, Warr R, Mills N, Havercroft D, Blazeby J. Assessment of cosmesis after breast reconstruction surgery: a systematic review. Ann Surg Oncol 2011; 18:813-23. [PMID: 20972633 DOI: 10.1245/s10434-010-1368-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breast reconstruction (BR) is undertaken to improve cosmetic outcomes, but how this is optimally assessed is uncertain. This review summarises current methods for assessing cosmesis after reconstructive surgery and makes recommendations for future practice. METHODS A comprehensive systematic review identified all studies with 20 or more participants that evaluated the cosmetic outcome of BR. Four evaluation criteria (reporting of study inclusion criteria, type and timing of BR and timing of assessment) were used to assess study quality. Articles reporting at least three of the four criteria were considered robust and further summarised to report methods of cosmetic assessment, assessor details and the scoring systems used. RESULTS 122 primary papers assessed cosmesis in 11,308 women with median follow-up of 28.8 months (range 18.0-42.9 months). Cosmesis was assessed by either healthcare professionals or patients in 33 (27.1%) and 37 studies (30.3%), respectively, and by both professionals and patients in 52 (42.6%). Professional assessments included 43 (40.2%) clinical, 49 (45.8%) photographic and 13 (12.1%) geometric assessments conducted by between 1 and 26 observers. Surgeons were most frequently involved in assessments (n = 71, 67.6%), but in 38 (36.1%) papers the assessor's profession was not reported. Twenty-seven (25.7%) papers used previously published assessment scale. Patients' views were assessed in 89 studies, using questionnaires (n = 63) or interviews (n = 12); 14 (15.7%) did not report how patients' views were obtained. CONCLUSIONS Current methods for assessing the cosmetic outcome of BR vary widely. A valid patient-centred assessment method is required to fully understand the outcomes of BR and to inform decision-making.
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Affiliation(s)
- Shelley Potter
- Academic Surgical Research Unit, School of Social and Community Medicine, University of Bristol, Bristol, UK.
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Colizzi L, Lazzeri D, Agostini T, Giannotti G, Ghilli M, Gandini D, Pantaloni M, Roncella M. Skin-reducing mastectomy: New refinements. J Plast Surg Hand Surg 2010; 44:296-301. [DOI: 10.3109/2000656x.2010.517681] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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An inferolateral approach to nipple-sparing mastectomy: optimizing mastectomy and reconstruction. Ann Plast Surg 2010; 65:140-3. [PMID: 20606592 DOI: 10.1097/sap.0b013e3181c1fe77] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
An increasing number of women presenting with early stage breast cancer or a strong family history are choosing mastectomy as a therapeutic or prophylactic treatment option. In these selected patients, conservation of the nipple areolar complex is considered to improve cosmesis and body image. Incision placement is an important consideration in breast appearance after surgery. Functionally, the incision must allow adequate access for mastectomy and implant positioning. In addition, preservation of blood supply is critical to maintain a viable nipple. This article describes an inferolateral curvilinear incision on the breast mound, which can be designed de novo or as an extension of a preexisting lateral scar. The incision allows adequate access and hides the scar on anterior view, thus optimizing both the mastectomy and reconstruction. In patients with a preexisting lateral scar, this may be the incision of choice.
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Nipple-sparing mastectomy with immediate implant reconstruction: cosmetic outcomes and technical refinements. Plast Reconstr Surg 2010; 126:1460-1471. [PMID: 21042102 DOI: 10.1097/prs.0b013e3181ef8bce] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy is gaining widespread popularity, as it could allow improved aesthetic outcome without increasing oncologic risk. To investigate the reconstructive issues experienced with immediate implant reconstruction, the authors reviewed the cosmetic outcomes of their series. METHODS The authors retrospectively analyzed the data on 33 cases of nipple-sparing mastectomy for both cancer and prophylaxis with immediate implant reconstruction using the submusculo-subfascial pocket. Cosmetic evaluation methods were clinical and photography-based assessments and a patient-satisfaction survey. RESULTS The average follow-up period was 26.8 months. No nipple-areola complex cancer involvement was registered. The reconstructive outcomes ranged from good to excellent in 83 percent of the cases. Patients' satisfaction was high to very high, except in one patient who experienced total nipple-areola complex loss (one breast, 2.4 percent). Overall, early minor complications were registered in four breasts (9.5 percent) and late minor complications in five cases (12 percent). CONCLUSIONS The authors' series suggest that nipple-sparing mastectomy is an option for carefully selected and screened patients. Larger studies with longer follow-up are needed, however. On the whole, the immediate one-stage implant reconstruction with hyperprojected anatomical gel implants represents a valid option. The skin incision algorithm proposed, which is based on the breast size, shape, and previous scars, might aid in the decision-making process to achieve satisfying results using this procedure. The radial approaches represent a good compromise between the oncologic and reconstructive procedures.
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Gravvanis A, Smith RW. Shaping the breast in secondary microsurgical breast reconstruction: Single- vs. two-esthetic unit reconstruction. Microsurgery 2010; 30:509-16. [DOI: 10.1002/micr.20792] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship Period. Plast Reconstr Surg 2010; 124:1-8. [PMID: 19568038 DOI: 10.1097/prs.0b013e3181ab10b2] [Citation(s) in RCA: 224] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Expander/implant and autogenous tissue breast reconstructions have different aging processes, and the time when these processes stabilize is unclear. The authors' goal was to evaluate long-term patient-reported aesthetic satisfaction with expander/implant and autogenous breast reconstruction. METHODS The authors surveyed a cross-section of University of Michigan women who underwent postmastectomy breast reconstruction (response rate, 73 percent) between 1988 and 2006 [110 expander/implant and 109 transverse rectus abdominis myocutaneous (TRAM) reconstructions]. Each group was stratified into three postreconstructive periods: short term (<or=5 years), intermediate (6 to 8 years), and long term (>8 years). Validated satisfaction items were scored on a 5-point Likert scale; scores were dichotomized into positive and negative responses. Logistic regression assessed satisfaction by procedure, while controlling for sociodemographic and clinical variables. RESULTS Mean follow-up time after reconstruction was 6.5 years (range, 1 to 18 years). Procedure type had no effect on short-term aesthetic satisfaction. However, in the long term, reconstruction type considerably affected satisfaction. Although satisfaction with TRAM reconstruction remained relatively constant, satisfaction with expander/implants was significantly less among those patients in the long term. Patients who had undergone implant reconstruction more than 8 years earlier, compared with those who undergone implant reconstruction less than 5 years earlier, were significantly less satisfied with breast appearance (odds ratio, 0.10; 95% CI, 0.02 to 0.48), softness (odds ratio, 0.14; 95% CI, 0.03 to 0.64), and size (odds ratio, 0.13; 95% CI, 0.03 to 0.62). CONCLUSIONS In the long term, TRAM patients, compared with expander/implant patients, appear to have significantly greater aesthetic satisfaction. These long-term data have important implications for women's health in the survivorship period and will help women navigate the complex decision-making process of breast reconstruction.
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Abstract
Abstract
Background
Although effective local control is the primary goal of surgery for breast cancer, the long-term aesthetic outcome is also important. Nipple-sparing mastectomy aims to address this, but there is no consensus on its clinical application. Evidence relating to oncological safety, surgical technique and early data on aesthetic outcome was reviewed.
Methods
The review was based on a PubMed search using the terms ‘nipple-sparing’ or ‘subcutaneous mastectomy’ and ‘breast cancer’.
Results
Large pathological studies report occult nipple involvement with cancer in 5·6–31 per cent, reflecting variation in inclusion criteria. Recent clinical series with careful patient selection report local recurrence in less than 5 per cent of patients. The incidence of cancer in the retained nipple after risk-reducing mastectomy is less than 1 per cent. Nipple necrosis rates range up to 8 and 16 per cent for total and partial necrosis respectively. Variations in outcome result from differences in extent of resection, placement of incisions and type of breast reconstruction.
Conclusion
Nipple-sparing mastectomy is an acceptable technique for women undergoing risk-reducing mastectomy. In the therapeutic setting, it may be offered to patients with smaller tumours far from the nipple and favourable pathological features. Women should be counselled about nipple necrosis and the potential for local recurrence.
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Affiliation(s)
- J E Rusby
- Academic Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - B L Smith
- Gillette Breast Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G P H Gui
- Academic Surgery, Royal Marsden NHS Foundation Trust, London, UK
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Chen CM, Disa JJ, Sacchini V, Pusic AL, Mehrara BJ, Garcia-Etienne CA, Cordeiro PG. Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction. Plast Reconstr Surg 2010; 124:1772-1780. [PMID: 19952633 DOI: 10.1097/prs.0b013e3181bd05fd] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The nipple is an uncommon site for breast cancer development, but the nipple-areola complex is routinely excised in breast cancer treatment. The authors evaluated the risks and benefits of nipple- or areola-sparing mastectomy with breast reconstruction. METHODS The authors analyzed data on 115 consecutive nipple- or areola-sparing mastectomies with immediate tissue expander breast reconstruction performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer center. Nipple-sparing mastectomies were performed for prophylaxis (n = 75) or treatment of disease (n = 40). RESULTS Mean patient age was 45 years (range, 24 to 61 years) and mean follow-up time was 22 months (range, 2 weeks to 91 months). There were 115 nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), including 111 nipple-sparing and four areola-sparing mastectomies. On pathologic review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer, 11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision placement was periareolar and radial (n = 61), inframammary (n = 25), omega type (n = 14), customized to include a previous scar (n = 10), or transareolar (n = 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost because of occult disease (5.2 percent), and four nipples were lost because of wound-healing problems (3.5 percent). CONCLUSIONS In the authors' series of nipple- and areola-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be feasible in selected patients and should be the subject of additional investigation.
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Affiliation(s)
- Constance M Chen
- New York, N.Y. From the Plastic and Reconstructive Service and the Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center
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DIEP flap with implant: a further option in optimising breast reconstruction. J Plast Reconstr Aesthet Surg 2009; 62:1118-26. [DOI: 10.1016/j.bjps.2007.12.089] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2007] [Revised: 10/31/2007] [Accepted: 12/16/2007] [Indexed: 11/22/2022]
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Calabrese C, Orzalesi L, Casella D, Cataliotti L. Breast reconstruction after nipple/areola-sparing mastectomy using cell-enhanced fat grafting. Ecancermedicalscience 2009; 3:116. [PMID: 22275994 PMCID: PMC3223994 DOI: 10.3332/ecancer.2009.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Indexed: 11/28/2022] Open
Abstract
Background: The success of fat grafting in breast reconstruction depends on fat retention. The use of stem-cells-enriched fat graft is an alternative method for graft stability. Case report: A case of nipple-areola sparing mastectomy double stage reconstruction with the use of stem cells enhanced fat graft is reported. Conclusions: Fat grafting is growing as a new and promising tool in reconstruction following nipple and areola sparing mastectomies as a way to restore a sufficient and reliable subcutaneous space in the mastectomy flap. This combined with an anatomical gel implant offers an integrated system of achieving a natural shaped breast.
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Affiliation(s)
- C Calabrese
- Breast Surgery Unit, Department of Oncology, University Hospital of Careggio, Florence, Italy
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The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg 2009; 249:461-8. [PMID: 19247035 DOI: 10.1097/sla.0b013e31819a044f] [Citation(s) in RCA: 263] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Abstract
PURPOSE OF REVIEW Presented is a brief overview of the current state of postmastectomy reconstruction. RECENT FINDINGS Breast reconstruction has been shown to have a positive effect on the psychological well being of women with breast cancer. Numerous studies have demonstrated that reconstruction performed concurrently with mastectomy is oncologically safe. Nevertheless, although increasing numbers of women are choosing to undergo postmastectomy reconstruction, this trend is inconsistent across demographic subgroups. In addition, the paradigm of performing immediate reconstruction on all-comers is being challenged by increasing use of postoperative radiotherapy. It is now appreciated that the implications of performing reconstruction in the setting of radiotherapy are both profound and controversial. Finally, questions are being raised about the factors that influence the ultimate surgical goal, namely patient satisfaction. It is anticipated that future investigations using newly developed, patient-reported outcome measures will provide important information about outcomes following reconstruction, which in turn will facilitate the decision-making process for both patients and surgeons. SUMMARY Recent refinements in surgical techniques and prosthetic technologies, development of novel tissue substitutes, and increasing use of adjuvant radiotherapy have led to changes in the practice of breast reconstruction following mastectomy.
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Gravvanis A, Caulfield RH, Ramakrishnan V, Niranjan N. A simple innovation to improve recipient vessel exposure in the axilla during microvascular breast reconstruction with DIEAP flap. Microsurgery 2008; 28:301-2. [PMID: 18381658 DOI: 10.1002/micr.20505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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