Risk factors and complications in free TRAM flap breast reconstruction

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis

BACKGROUND

Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data.

METHODS

Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.

RESULTS

From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively.

CONCLUSION

Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

Latissimus Dorsi Flap and Thoracodorsal Artery Perforator Flap with Immediate Fat Transfer (LIFT and TIFT): A Retrospective Study about Total Breast Reconstruction in High-Risk Patients

INTRODUCTION

Microsurgical breast reconstruction has become popular over the past twenty years and allows a tailor-tuck approach to each patient. However, smoking or coagulation disorders may switch surgeon's choice towards alternative options. When facing these risk factors, we performed pedicled latissimus dorsi (LD) flap and thoracodorsal artery perforator (TDAP) flap reconstruction with immediate fat transfer (LIFT and TIFT), achieving satisfactory surgical outcomes. Hence, we aim to present our seven-years case-series and discuss our decisional algorithm.

MATERIALS AND METHODS

Thirty smoker women and seven women affected by coagulation disorder (n = 37) respectively had LIFT and TIFT surgery and were retrospectively evaluated. Patients' demographics and outcomes were recorded and compared.

RESULTS

LIFT patients received higher volumes of immediate fat grafting compared to TIFT patients (p < 0.05), which required additional lipofilling to provide adequate volume amount, since the TDAP flap was not immediately grafted. However, the additional lipofilling procedures and fat volume were similar (p > 0.05). Flap survival reached 100%, and flap necrosis or loss did not occur. Few minor complications were evidenced in the LIFT group only (p > 0.05).

CONCLUSION

Based on our experience, we support the reliability of pedicled LD and TDAP flaps with immediate fat transfer in breast reconstruction as valuable alternative to microsurgery in smokers (LIFT) and patients with coagulation disorders (TIFT). However, the results of our study are not conclusive since still must be clarified the role of the smoking and coagulation disorders in microsurgery and the real benefit of a non-microsurgical procedure.

LEVEL OF EVIDENCE IV

Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

The treatment of symptomatic fat necrosis: A review and introduction of a new treatment algorithm

OBJECTIVE

Fat necrosis (FN) is a well-known complication in plastic surgery. Excision of symptomatic FN has been the gold standard, but it often results in contour irregularities that require subsequent treatment. Different alternative surgical and nonsurgical management strategies have been described; however, there are currently no guidelines. This literature review aims to provide an overview of available treatment options and current management standards to support clinical decision making.

METHOD

A literature search in the databases PubMed, Embase (via Ovid), and Web Of Science was carried out to identify eligible articles. The search strategy included combinations of the following terms: "Fat necrosis "AND (treatment OR management OR therapy). Six articles discussing or reporting management strategies of FN in a plastic surgery context were included.

RESULTS

A variety of techniques were used to manage symptomatic FN. Asymptomatic or small lesions can be treated conservatively. Oil cyst and moderately sized areas of symptomatic FN can effectively be treated by aspiration, ultrasound-assisted liposuction, or needle aeration. Calcified and large areas of FN require excision and debridement of necrotic fat tissue CONCLUSION: At present, there is no consensus on the management of symptomatic FN. The authors propose a new classification system to aid the guidance of management of symptomatic FN.

Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis

Breast reconstruction (BR) is a unique surgical procedure that provides patients undergoing mastectomy with significant psychosocial and aesthetic benefits and has also become a crucial part of the treatment pathway for women with breast cancer. Due to methodological inadequacies and the absence of substantial risk factor analysis, no conclusion can be drawn about the correlation between risk variables and post-surgical complications in BR surgery. We aim to identify the potential risk factors associated with postoperative complications.

Methods

We queried MEDLINE and Cochrane CENTRAL from their inception to March 2022, for published randomized controlled trials and observational studies that assessed complications post-reconstruction procedure in breast cancer patients following mastectomy or evaluated at least one of the following outcomes of major or reoperative complications. The results from the studies were presented as odds ratios with 95% confidence intervals and were pooled using a random-effects model.

Results

Our pooled analysis demonstrated a significant correlation with BR postoperative complications and risk factors such as diabetes, hypertension, and obesity. Diabetes and the development of seroma were found to have a significant relationship. Risk variables such as age, radiotherapy, COPD, and smoking had no significant connection with 0-to-30-day readmission and 30-to-90-day readmission.

Conclusion

This meta-analysis shows that risk factors like age, smoking history, high blood pressure, and body mass index (BMI) have a big effect on complications after BR, and patients with risk factors have a high rate of developing infection.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

The effect of sarcopenic obesity and muscle quality on complications after DIEP-flap breast reconstruction

Introduction

The aim of this study was to evaluate whether sarcopenic obesity and muscle quality as expressed by skeletal muscle radiodensity (SMD) are associated to postoperative complications in women undergoing DIEP-flap breast reconstruction (BR).

Methods

All patients who underwent DIEP-flap BR at our tertiary center between 2010 and 2018 were asked to sign informed consent for the use of their electronic medical records and images. By outlining anatomical skeletal muscle contours on the preoperative abdominal CT-scan at lumbar level L3, SMD and skeletal muscle indices (SMI) were measured by two observers independently. Using logistic regression analyses, the association between sarcopenic obesity (BMI >25 & SMI <39), low SMD (<40HU), and Clavien-Dindo (CD) grade ≥ II complications was evaluated. In this way odds ratios (OR) and adjusted odds ratios (OR_adjusted) were provided.

Results

Out of the 103 patients included in this study, 36% had CD grade ≥ II complications within 30 days of surgery. Twenty patients (19%) suffered from sarcopenic obesity of whom eleven patients (55%) had CD grade ≥ II complications (OR = 2.7, p = 0.05). In a multivariate analysis, sarcopenic obesity was not significantly related to a higher complication rate (OR_adjusted = 2.2, p = 0.14) but women with SMD below average and those with prior radiotherapy had a higher risk for grade ≥ II complications (OR_adjusted = 2.9, p = 0.02 and OR_adjusted = 2.7, p = 0.02 respectively).

Conclusion

Below average SMD (<40HU) was found to be associated with the development of postoperative CD grade ≥ II complications in women undergoing DIEP-flap BR. Future research should evaluate whether improving SMD reduces the complication incidence in this patient group.

Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction

BACKGROUND

Psychological factors are broadly understood to contribute to overall health, but their contribution to wound healing is less well defined. Limited data exist on the association of preoperative psychological factors such as body image and postoperative complications. The present study analyzed the association between preoperative body image factors and postoperative complications following breast reconstruction.

METHODS

This was a prospective cohort study of 302 breast cancer patients undergoing breast reconstruction from 2011 to 2015. All patients completed the BREAST-Q; demographics, surgical details, and postoperative complications were recorded. The association of body image factors by means of the BREAST-Q and postoperative complications was analyzed.

RESULTS

On univariate analysis, patients who reported lower preoperative satisfaction with how they appeared in the mirror unclothed, or felt less self-confident or attractive, were significantly more likely to develop an infection postoperatively. Preoperative satisfaction scores were not associated with complications when analyzed in a multivariate fashion. On binomial logistic regression analysis, after controlling for age, body mass index, reconstruction technique, and use of radiotherapy, patients who reported less preoperative satisfaction with how comfortably bras fit or how they appeared in a mirror unclothed were at an increased risk for delayed wound healing.

CONCLUSIONS

Patients with lower preoperative body satisfaction were found to have an increased incidence of infections and delayed wound healing. Although postoperative outcomes are multifactorial, the data suggest that baseline psychological factors such as body image may play a role in postoperative outcomes. Broader use of prehabilitative therapies, targeted at psychosocial factors, may warrant further investigation to optimize postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Patient Management Strategies in Perioperative, Intraoperative, and Postoperative Period in Breast Reconstruction With DIEP-Flap: Clinical Recommendations

Background and Objective

Deep Inferior Epigastric Perforator (DIEP) flap is a tissue isolated from the skin and subcutaneous tissue of the lower abdomen or rectus muscle to foster breast reconstruction. There is limited information about DIEP-flap induced complications associated with breast reconstruction surgery.

Evidence

We conducted a systematic review of the published literature in the field of breast cancer reconstruction surgery. Information was gathered through internet resources such as PubMed, Medline, eMedicine, NLM, and ReleMed etc. The following key phrases were used for effective literature collection: “DIEP flap”, “Breast reconstruction”, “Patient management”, “Postoperative DIEP”, “Intraoperative anticoagulant therapy”, “Clinical recommendations”. A total of 106 research papers were retrieved pertaining to this systematic review.

Conclusion

A successful breast reconstruction with DIEP-flap without complications is the priority achievement for this surgical procedure. This study provides various evidence-based recommendations on patient management in the perioperative, intraoperative, and postoperative periods. The clinical recommendations provided in this review can benefit surgeons to execute breast reconstruction surgery with minimal postoperative complications. These recommendations are beneficial to improve clinical outcomes when performing surgery by minimizing complications in perioperative, intraoperative, and postoperative period.

The Impact of Race on Perioperative and Patient-Reported Outcomes following Autologous Breast Reconstruction

BACKGROUND

Racial disparities are evident in multiple aspects of the perioperative care of breast cancer patients, but data examining whether such differences translate to clinical and patient-reported outcomes are limited. This study examined the impact of race on perioperative outcomes in autologous breast reconstruction.

METHODS

A retrospective cohort study including all breast cancer patients who underwent immediate autologous breast reconstruction at a single institution from 2010 to 2017 was conducted. Self-reported race was used to classify patients into three groups: white, African American, and other. The primary and secondary endpoints were occurrence of any major complications within 30 days of surgery and patient-reported outcomes (measured with the BREAST-Q), respectively. Regression models were constructed to identify factors associated with the outcomes.

RESULTS

Overall, 404 patients, including 259 white (64 percent), 63 African American (16 percent), and 82 patients from other minority groups (20 percent), were included. African American patients had a significantly higher proportion of preoperative comorbidities. Postoperatively, African American patients had a higher incidence of 30-day major complications (p = 0.004) and were more likely to return to the operating room (p = 0.006). Univariable analyses examining complications demonstrated that race was the only factor associated with 30-day major complications (p = 0.001). Patient-reported outcomes were not statistically different at each time point through 3 years postoperatively.

CONCLUSIONS

African American patients continue to present with increased comorbidities and may be more likely to experience major complications following immediate autologous breast reconstruction. However, patient-reported satisfaction or physical well-being outcomes may not differ between groups.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Characterization of Baseline Temperature Characteristics Using Thermography in The Clinical Setting

BACKGROUND

Thermography is a diagnostic method based on the ability to record infrared radiation emitted by the skin and is unique in its ability to accurately show physiological and/or pathological cutaneous temperature changes in a non-invasive way. This method can be used to indirectly assess changes or impairments in cutaneous perfusion. Significant technological advancements have allowed thermography to be more commonly utilized by clinicians, yet a basic consensus of patient characteristics that may affect temperature recordings is not established.

MATERIALS AND METHODS

We evaluated cutaneous temperature in a cohort of outpatients to understand what factors, including tobacco use and other high-risk characteristics, contribute to cutaneous tissue perfusion as measured by thermography. Participants were prospectively enrolled if they were a combustible cigarette smoker, an electronic cigarette (e-cigarette) user, or a never smoker. Standardized thermographic images of the subject's facial profiles, forearms, and calves were taken and demographic characteristics, medical comorbidities, and tobacco product use were assessed. These variables were statistically tested for associations with temperature at each anatomic site.

RESULTS

We found that gender had a significant effect on thermographic temperature that differed by anatomic site, and we found a lack of significant difference in thermographic temperature by race. Our regression analysis did not support significant differences in thermographic temperatures across smoking groups, while there was a trend for decreased perfusion in smokers relative to non-smokers and e-cigarette users relative to non-smokers.

CONCLUSION

Thermographic imaging is a useful tool for clinical and research use with consideration of sex and other perfusion-affecting characteristics.

Successful umbilicus salvage following concurrent infraumbilical single-port myomectomy and free transverse rectus abdominis myocutaneous flap elevation: a case report

Performing a concurrent gynecologic operation and mastectomy with immediate breast reconstruction using a free transverse rectus abdominis myocutaneous flap may increase the risk of complications such as umbilical necrosis due to vascular compromise. Imaging studies such as preoperative computed tomography angiography and intraoperative indocyanine green testing can provide information regarding the umbilical blood supply, facilitating decision-making for pedicle selection. Therefore, in situations where a coordinated operation is unavoidable, a thorough preoperative and intraoperative evaluation of the umbilical blood supply is recommended to avoid complications.

Modified Frailty Index (mFI) predicts 30-day complications after microsurgical breast reconstruction

Frailty lacks a universal definition. The modified Frailty Index (mFI) using patient comorbidities can be used to measure frailty. We hypothesized that mFI predicts 30-day complications after microsurgical breast reconstruction. American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) was investigated to identify patients undergoing microsurgical breast reconstruction between 2005-2014 using Current Procedure Terminology (CPT) code, 19364. We used mFI as a measure of frailty. The patients were assigned a frailty score based on the number of preoperative comorbid conditions as defined by the mFI. Other risk indices used include age, BMI, wound class, ASA class. Stratification was performed in ascending order for each. The outcome measure was aggregate 30-day complications. Regression analysis was performed followed by Receptor Operating Characteristic (ROC) curve to determine the accuracy of each risk index in predicting 30-day complications. Of the 3237 patients 24% experienced complications. Univariate logistic regression analysis found odds ratio of complications for frailty score 1 = 22.1 (CI = 17.9-27.3, p < 0.01), and 2 = 28 (CI = 18.3-43, p < 0.01) compared to frailty score = 0. ROC curve demonstrated mFI with the highest concordance score (c-score = 0.816). Multivariable logistic regression found frailty as the strongest independent predictor of 30-day aggregate complications adjusted OR = 22.24, CI = 17.77-27.82, p < 0.01 when compared to other risk indices. The modified Frailty Index is a simple, reliable, and objective tool that can be used to predict postoperative complications after microsurgical breast reconstruction. The application of this tool can help microsurgeons preoperatively identify patients who are at high risk.Abbreviations: ACS: American College of Surgeons; ASA: American Society of Anesthesiologists; BMI: body mass index; CHF: congestive heart failure; CPT: current procedural terminology; COPD: chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DM: diabetes mellitus; IRB: institutional review board; mfi: modified frailty index; MI: myocardial infarction; NSQIP: national surgical quality improvement program; PVD: peripheral vascular disease; ROC: receptor operating characteristic; TIA: transient ischemic attach.

Short- and long-term outcomes of immediate breast reconstruction surgery after neoadjuvant chemotherapy

PURPOSE

Immediate breast reconstruction (IBR) is a standard option for breast cancer patients, although its utility in patients with advanced breast cancer requiring neoadjuvant chemotherapy (NAC) is debatable. We assessed the short-term complications and long-term prognosis of IBR after NAC.

METHODS

We retrospectively analyzed 1135 patients with IBR and/or NAC between 2010 and 2018, 43 of whom underwent IBR after NAC.

RESULTS

Twenty-five patients underwent reconstruction with a tissue expander (TE) followed by silicon breast implantation, 5 with a latissimus dorsi muscle transfer flap, and 13 with a deep inferior epigastric perforator flap. Complete surgical resection with a free margin confirmed by a pathological assessment was achieved in all patients. The evaluation of the short-term complications indicated no cases of total flap necrosis, two cases of partial flap necrosis, and one case of wound infection. Only one case required postponement of subsequent therapy due to partial flap necrosis. A long-term evaluation indicated no local recurrence, although distant metastasis was observed in 4 cases, 3 patients died, and TE removal after post-mastectomy radiotherapy (PMRT) was performed in 2 of 11 TE cases.

CONCLUSION

IBR may be a viable option in patients with advanced breast cancer who achieve complete surgical resection after NAC.

Protocol for a multicentre, prospective, cohort study to investigate patient satisfaction and quality of life after immediate breast reconstruction in Japan: the SAQLA study

INTRODUCTION

The aim of breast reconstruction (BR) is to improve patients' health-related quality of life (HRQOL). Therefore, measuring patient-reported outcomes (PROs) would clarify the value and impact of BR on a patient's life and thus would provide evidence-based information to help decision-making. The Satisfaction and Quality of Life After Immediate Breast Reconstruction study aimed to investigate satisfaction and HRQOL in Japanese patients with breast cancer who undergo immediate breast reconstruction (IBR).

METHODS AND ANALYSIS

This ongoing prospective, observational multicentre study will assess 406 patients who had unilateral breast cancer and underwent mastectomy and IBR, and were recruited from April 2018 to July 2019. All participants were recruited from seven hospitals: Okayama University Hospital, Iwate Medical University Hospital, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Showa University Hospital, University of Tsukuba Hospital, Osaka University Hospital and Yokohama City University Medical Center. The patients will be followed up for 36 months postoperatively. The primary endpoint of this study will be the time-dependent changes in BREAST-Q satisfaction with breast subscale scores for 12 months after reconstructive surgery, which will be collected via an electronic PRO system.

ETHICS AND DISSEMINATION

This study will be performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects published by Japan's Ministry of Education, Science and Technology and the Ministry of Health, Labour and Welfare, the modified Act on the Protection of Personal Information and the Declaration of Helsinki. This study protocol was approved by the institutional ethics committee at the Okayama University Graduate School of Medicine, Dentistry, on 2 February 2018 (1801-039) and all other participating sites. The findings of this trial will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

UMIN000032177.

The development of laminin-alginate microspheres encapsulated with Ginsenoside Rg1 and ADSCs for breast reconstruction after lumpectomy

Many technologies have been developed for breast reconstruction after lumpectomy. Although the technologies achieved promising success in clinical, there are still many shortages hanging over and trouble the researchers. Tissue engineering technology was introduced to plastic surgery that gave a light to lumpectomy patients in breast reconstruction. The unexpected absorption rate, resulting from limited vascularization and low cell survival rate, is a major factor that leads to unsatisfactory results for the previous studies in our lab. In the study, the laminin-modified alginate synthesized by a new method of low concertation of sodium periodate would be mixed with ADSCs and Rg1 in the medium; and then sprayed into a calcium chloride (CaCl₂) solution to prepare into microsphere (abbreviated as ADSC–G-LAMS) by bio-electrospray with a power syringe for the mass production and smaller bead size. The developed ADSC–G-LAMS microspheres had the diameter of 232 ± 42 μm. Sustained-release of the Rg1 retained its biological activity. WST-1, live/dead staining, and chromosome aberration assay were evaluated to confirm the safety of the microspheres. In in vivo study, ADSC–G-LAMS microspheres combined with autologous adipocytes were transplanted into the dorsum of rats by subcutaneous injection. The efficacy was investigated by H&E and immunofluorescence staining. The results showed that the bioactive ADSC–G-LAMS microspheres could integrate well into the host adipose tissue with an adequate rate of angiogenesis by constantly releasing Rg1 to enhance the ADSC or adipocyte survival rate to join tissue growth and repair with adipogenesis for breast reconstruction after lumpectomy.

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Laminin-modified alginate was successfully synthesized to mimic early embryonic environment.

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Adipose-derived stem cells (ADSCs) and ginsenoside Rg1 were encapsulated into laminin-alginate microspheres (ADSC–G-LAMS) by bio-electrospray method.

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ADSC–G-LAMS microspheres integrated into the host adipose tissue with an adequate rate of angiogenesis by constantly releasing Rg1.

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The developed bioactive ADSC–G-LAMS microspheres can be potential scaffolds for stem cells and angiogenic factor carriers for tissue engineering.

The Lateral Breast Flap Sling: A Novel Technique for the Revision of Autologous Breast Reconstructions

Introduction

A wide breast footprint is a common complaint expressed by breast reconstruction patients following abdominally-based autologous breast reconstruction. Our aim is to describe the lateral autologous breast sling, a novel technique, which modifies the lateral flap inset to address this common patient complaint.

Methods

A review of consecutive women who underwent the lateral autologous breast flap sling procedure over a four-year period was completed. Patient demographics, oncologic treatment, operative interventions, surgical indications, and complications were evaluated.

Results

Fourteen patients underwent 21 lateral autologous breast flap sling procedures with a mean follow-up of 18 months. Eleven patients underwent delayed breast reconstruction while three were completed immediately, including one patient who had concurrent unilateral mastectomy, free tissue transfer, and a lateral breast sling procedure. Revision surgery was sought for breast asymmetry, excessive lateral breast tissue, and poor superior pole volume. Simultaneous revision procedures were performed in 12 patients and included fat grafting, abdominal donor site revision, contralateral breast reduction, and V to Y advancement of the lateral breast/ chest soft tissues. Reconstruction was complete in 10 patients, with an average duration of 13.5 months and four reconstructive procedures. There were no major perioperative complications. Three patients developed fat necrosis following lipofilling and two of these patients required drainage and/or excision of fat necrosis.

Conclusions

The lateral autologous breast flap sling technique adds to the armamentarium for narrowing the wide breast and improving the lateral breast curve. It may be performed in combination with other revision procedures. The use of this technique is associated with a low complication rate and does not significantly increase the total number of reconstructive procedures or duration of reconstruction. This technique may be useful during initial free tissue transfer.

Autologous tissue reconstruction after mastectomy-A cross-sectional survey of 110 hospitals in China

BACKGROUND

Autologous reconstruction after mastectomy became more and more popular, so this study aimed to obtain up-to-date and comprehensive data on autologous reconstruction in China.

METHODS

An electronic questionnaire was sent to 110 hospitals, which were chosen depending on geographical distribution and hospital types. The questionnaire investigated the demographics, characteristics, breast cancer treatment and reconstruction situation of these hospitals through different modules. We only focused on the autologous breast reconstruction module data.

RESULTS

96 hospitals have performed breast reconstruction surgery. The proportion of the hospital performing latissimus dorsi flap (LDF, N = 91), pedicle transverse rectus abdominis myocutaneous flap (pTRAM, N = 62), free abdominal flap (N = 43) and other kinds of flap decreased in sequence. Of the overall reconstruction cases, only 34.3% were autologous reconstruction and LDF was still the most popular option for autologous reconstruction. Related factors of hospital performing different procedures included years of performing breast reconstruction, breast surgical volume, and establishment of an independent plastic surgery department. Compared with LDF, abdominal breast reconstruction was associated with a higher flap necrosis rate.

CONCLUSIONS

This cross-sectional survey offers real-life autologous reconstruction information on a large population and covers the national surgical landscape in China. Autologous reconstruction is still an important part of breast reconstruction. Nevertheless, its low proportion and lower proportion of abdominal flap reconstruction in each institution, demonstrates that special training should be developed for breast surgeons and multidisciplinary cooperation would be promoted in the future.

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case-Control Study

OBJECTIVE

To identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion.

MATERIALD AND METHODS

This is a case-control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion.

RESULTS

In total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m² (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m² (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]).

CONCLUSION

Smoking status, age under 55 years, BMI below 30 kg/m², fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Neoadjuvant Radio(chemo)therapy for Breast Cancer: An Old Concept Revisited

Background: The international standard of care for the treatment of high-risk breast cancer (BC) consists of neoadjuvant chemotherapy (NACT) and surgery followed by adjuvant whole breast/chest wall irradiation. In this setting, the time interval from the start of NACT to the end of radiotherapy (RT) is usually postponed to 6 months or longer. In addition to this, a high percentage of capsular fibrosis may occur when breast implants are irradiated. Most of these disadvantages could be avoided by using preoperative RT (PRT). PRT is already the standard of care in several other tumor entities (rectal cancer, esophagus carcinoma, lung cancer, and soft tissue sarcoma). Nevertheless, PRT in BC has been tested in several trials, but randomized prospective trials using modern radiation technology and systemic therapies are lacking. The available evidence summarized in this review indicates that PRT may improve survival and reduce long-term toxicity in patients with a higher risk of recurrence and should be consequently tested in a randomized trial. Summary: Prospective, randomized trials concerning PRT in high-risk BC are needed. We plan to conduct a NeoRad trial (NACT followed by PRT in high-risk BC). Key Messages: Prospective, randomized studies concerning PRT in high-risk BC are needed.

Effects of neoadjuvant chemotherapy on operative adverse events and chemotherapy and radiotherapy in patients undergoing immediate breast reconstruction

BACKGROUND

Immediate breast reconstruction (IBR) has been become a standard treatment for patients with breast cancer undergoing mastectomy. However, whether IBR is appropriate in patients undergoing neoadjuvant chemotherapy (NAC) is still unclear. Therefore, in this study we examined the rates of operative adverse events (AEs), risk factors for operative AEs, and effects on chemotherapy and radiotherapy of IBR with NAC.

METHODS

Between January 2012 and March 2018, 593 patients underwent IBR at the Aichi Cancer Center Hospital. We retrospectively obtained clinical data of all these patients from their medical records and identified 56 patients (65 breasts) who had received NAC (NAC group) and 537 patients (568 breasts) who had not (non-NAC group). We compared the rates of operative AEs, risk factors for operative AEs, chemotherapy-related AEs, and duration to radiotherapy between the NAC and non-NAC cohorts.

RESULTS

The rate of operative AEs was significantly higher in the NAC than the non-NAC group (35% vs. 22%, p < 0.05). However, axillary lymph node dissection was the most influential risk factor, and NAC was not identified as a risk factor for operative AEs in patients who had undergone IBR. Additionally, there were no statistically significant differences in chemotherapy-related AEs or interval between surgery and postoperative radiotherapy between the NAC and non-NAC groups.

CONCLUSIONS

NAC remains likely to contribute to increased postoperative AEs in patients undergoing IBR; however, it does not affect postoperative treatment and IBR is appropriate for patients undergoing NAC.

Association of Smoking and Other Factors With the Outcome of Mohs Reconstruction Using Flaps or Grafts

Importance

Smoking, a common lifestyle trait, is considered by many surgeons to be a major risk factor for postoperative complications. However, in the literature on local reconstruction, the association between smoking and the rate of postoperative complications after cutaneous tissue transfer is not well characterized.

Objective

To study the outcomes of flaps and grafts used in Mohs micrographic surgery reconstruction with respect to smoking status and patient-specific and surgery-specific variables.

Design, Setting, and Participants

This retrospective case-control study was conducted at a single tertiary referral center among 1008 patients who underwent Mohs reconstruction repaired by flap or graft between July 1, 2012, and June 30, 2016, and were selected via consecutive sampling. Cases with incomplete records or those in which a single flap or graft was used to repair multiple defects were excluded. Data analysis was performed from September 2017 to January 2018.

Main Outcomes and Measures

Postoperative acute and long-term complications. Acute complications included postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention. Long-term complications included functional or cosmetic outcomes that prompted the patient to request or the surgeon to offer additional intervention.

Results

Of the 1008 patients included in the study (396 women and 612 men), the median (SD) age was 70 (12) years (range, 21-90 years). A total of 128 patients (12.7%) were current smokers, 385 (38.2%) were former smokers, and 495 (49.1%) were never smokers. On multivariate logistic regression, current smoking (odds ratio [OR], 9.58; 95% CI, 3.63-25.3), former smoking (OR, 3.64; 95% CI, 1.41-9.38), larger defect size (OR, 2.25; 95% CI, 1.58-3.20), and the use of free cartilage graft (OR, 8.19; 95% CI, 2.02-33.1) were associated with increased risks of acute complications. For long-term complications, central face location (OR, 25.4; 95% CI, 6.16-106.5), use of interpolation flap or flap-graft combination (OR, 3.49; 95% CI, 1.81-6.74), larger flap size (OR, 1.42; 95% CI, 1.09-1.87), and basal cell carcinomas or other basaloid tumors (OR, 3.43; 95% CI, 1.03-11.5) were associated with an increased risk, whereas increased age (OR, 0.66 per 10-year interval; 95% CI, 0.54-0.80) was associated with decreased risk.

Conclusions and Relevance

This study suggests that both current and former smokers are at increased risk for acute postsurgical complications but that smoking status is not associated with long-term complications. These findings may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling.

Level of Evidence

3.

Free-flap breast reconstruction on experimental porcine model

INTRODUCTION

Free flaps require mastering microsurgical technique. In addition, breast reconstruction implies accuracy not only in flap survival, but also satisfying aesthetic outcome. Thus, such complex abilities can be acquired by creating experimental models for surgical training.

MATERIALS AND METHODS

In accordance with relevant anatomy data found in literature, we chose a porcine model and performed a flap similar to the human deep inferior epigastric perforator (DIEP). Furthermore we developed a surgical protocol for a free flap transfer similar to a double-pedicle DIEP flap. The adipo-cutaneous flap was harvested as a free flap based on the superior abdominal vascularization and microsurgical anastomoses were performed to both the internal thoracic and thoracodorsal vessels.

RESULTS

We were able to harvest a superior epigastric double-perforator free flap with increased similarity to the human DIEP flap. Microsurgical anastomoses were possible to both to the internal thoracic vessels and thoracodorsal vessels, which both proved to have optimal caliber for termino-terminal anastomosis.

CONCLUSION

Although there are several differences when comparing a swine experimental model with human anatomy, our protocol enhances the possibilities for training in breast reconstruction.

Association between blood pressure and postoperative hematomas in the patients undergoing head and neck cancer reconstruction

BACKGROUND

Postoperative hematoma is one of the most common complications of free flap reconstruction and compromises the perfusion of pedicles and perforators. Therefore, we reviewed our patients to analyze the associated risk factors.

METHOD

This study involved a retrospective chart review from 2014 to 2016. We identified the patients undergoing free flap reconstructions for head and neck cancer. Patients with postoperative hematoma requiring surgical intervention were included.

RESULT

We enlisted 289 patients undergoing head and neck reconstructions. Eighteen patients (6.2%) had postoperative hematomas of which 12 hematomas occurred within the first 3 days and 9 in the first 24 hours. Elevated systolic blood pressure increased the risk of hematoma formation, but hematoma was not associated with higher failure rate. Tachycardia was observed in the patients with hematoma.

CONCLUSIONS

Transient elevated blood pressure increased the risk of hematoma. We suggest controlling systolic blood pressure below 150 mm Hg for prevention of hematoma.

Neoadjuvant Chemotherapy does not Increase Complications in Oncoplastic Breast-Conserving Surgery

BACKGROUND

Oncoplastic breast-conserving surgery (OBCS) broadens the indications for breast conservation. Neoadjuvant systemic chemotherapy (NAC) is used increasingly in the treatment of patients with early-stage and locally advanced breast cancer. This study aimed to evaluate the outcomes for patients who received NAC followed by OBCS.

METHODS

A retrospective chart review was performed for all patients who underwent OBCS involving the mastopexy/breast-reduction technique, including synchronous mastopexy/breast reduction for symmetry, at the University of Texas MD Anderson Cancer Center between January 2010 and January 2016. Patients who had received NAC were compared with those who had undergone surgery first. Demographic, treatment, and outcomes data were collected.

RESULTS

The study included 429 patients, corresponding to 713 breasts. Of these patients, 122, corresponding to 199 breasts, received NAC. The patients who received NAC were younger (p < 0.001) and had a more advanced cancer stage (p < 0.001). The overall complication rate per patient was 25.9%, with major complications occurring in 9.1% of the patients. After adjustment for risk factors, NAC was not shown to be associated with an increased risk of complications or delayed adjuvant radiation therapy (p = 0.37), irrespective of the chemotherapy regimen used or whether the interval between NAC and surgery was 4 weeks or longer.

CONCLUSIONS

In a high-volume center, OBCS can be performed safely for carefully selected patients after NAC without an increased risk of complications or delayed adjuvant radiation therapy. An interval of at least 4 weeks between completion of NAC and surgery can be regarded as safe irrespective of the chemotherapy regimen used.

The Effect of Smoking and Body Mass Index on The Complication Rate of Alloplastic Breast Reconstruction

BACKGROUND AND AIMS

The aim of this study was to evaluate the effect of smoking and body mass index on the occurrence of complications after alloplastic breast reconstruction.

MATERIALS AND METHODS

A consecutive series of 56 patients treated with immediate or delayed alloplastic breast reconstruction, including six cases combined with latissimus dorsi flap, at three hospitals between 2012 and 2018 were included. Complications were scored and defined according to Clavien-Dindo. To evaluate the impact of smoking, body mass index, and other potential risk factors on the occurrence of any and severe complications, univariate and multivariate logistic regression analyses were applied to estimate odds ratios and 95% confidence intervals.

RESULTS

In 56 patients, 22 patients had a complication. As much as 46% of smokers had severe complications compared to 18% of non-smokers. Of patients with body mass index ⩾ 25, 40% had severe complications compared to 10% with body mass index < 25. Smokers had eight times more chance of developing severe complications than non-smokers (OR_adjusted = 8.0, p = 0.02). Patients with body mass index ⩾ 25 had almost 10 times more severe complications compared to patients with body mass index ⩽ 25 (OR_adjusted = 9.9, p = 0.009). No other risk factors were significant.

CONCLUSION

Smoking and body mass index ⩾ 25 both increased the complication rate to such an extent that patients should be informed about their increased risk for complications following alloplastic breast reconstruction and on these grounds surgeons may delay alloplastic breast reconstruction. It is an ethical dilemma whether one should deny overweight and obese patients and those who smoke an immediate alloplastic breast reconstruction. For both life style interventions, adequate guidance should be made available.

Persistent disparities in breast cancer surgical outcomes among hispanic and African American patients

BACKGROUND

Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized.

METHODS

Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race.

RESULTS

A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients.

CONCLUSIONS

Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.

Impact of Body Mass Index on Operative Outcomes in Head and Neck Free Flap Surgery

Objective

Analyze the risk for perioperative complications associated with body mass index (BMI) class in patients undergoing head and neck free flap reconstruction.

Study Design and Setting

Retrospective cohort study.

Subjects and Methods

The National Surgical Quality Improvement Program (NSQIP) database was queried for all cases of head and neck free flaps between 2005 and 2014 (N = 2187). This population was stratified into underweight, normal-weight, overweight, and obese BMI cohorts. Groups were compared for demographics, comorbidities, and procedure-related variables. Rates of postoperative complications were compared between groups using χ2 and binary logistic regression analyses.

Results

Underweight patients (n = 160) had significantly higher rates of numerous comorbidities, including disseminated cancer, preoperative chemotherapy, and anemia, while obese patients (n = 447) had higher rates of diabetes and hypertension. Rates of overall surgical complications, medical complications, and flap loss were insignificantly different between BMI groups. Following regression, obese BMI was protective for perioperative transfusion requirement (odds ratio [OR] = 0.63, P = .001), while underweight status conferred increased risk (OR = 2.43, P < .001). Recent weight loss was found to be an independent predictor of perioperative cardiac arrest (OR = 3.16, P = .006) while underweight BMI was not (OR = 1.21, P = .763). However, both weight loss and underweight status were associated with significantly increased risk for 30-day mortality (OR = 4.48, P = .032; OR = 4.02, P = .010, respectively).

Conclusion

Obesity does not increase the risk for postoperative complications in head and neck free flap surgery and may be protective in some cases. When assessing a patient’s fitness for surgery, underweight status or recent weight loss may suggest a reduced ability to tolerate extensive free flap reconstruction.

Does Hormone Therapy Use Increase Perioperative Complications in Abdominally Based Microsurgical Breast Reconstruction?

BACKGROUND

The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. As breast cancer patients undergoing microsurgical breast reconstruction are often receiving hormone therapy, it is unclear whether this increased thrombotic risk is associated with increased flap loss.

METHODS

A retrospective review was performed on patients undergoing abdominally based microsurgical breast reconstruction at an academic institution from 2004 to 2015. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including complete or partial flap loss and overall complications, were compared and analyzed using univariate and logistic regression models.

RESULTS

Among a total of 853 patients (1253 flaps), 193 patients (269 flaps) were receiving hormone therapy and 660 patients (984 flaps) were not. Patients on hormone therapy had higher rates of previous breast surgery, advanced cancer stage, chemoradiation before reconstruction, and delayed and unilateral reconstruction. There were no statistically significant differences between hormone therapy patients and nontherapy patients in complete flap loss (1.0 percent versus 1.1 percent) and partial flap loss (2.2 percent versus 1.5 percent). Hypertension and previous breast surgery were the only independent risk factors for minor complications (adjusted OR, 2.1; 95 percent CI, 1.3 to 3.6; p = 0.005; and adjusted OR, 1.8; 95 percent CI, 1.2 to 2.7; p = 0.009, respectively) and overall complications (adjusted OR, 2.2; 95 percent CI, 1.3 to 3.7; p = 0.004; and adjusted OR, 1.9; 95 percent CI, 1.3 to 3.0; p = 0.003, respectively).

CONCLUSIONS

Hormone therapy was not associated with a higher incidence of complete or partial flap loss or overall complications. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current evidence on the role of smoking in plastic surgery elective procedures: A systematic review and meta-analysis

BACKGROUND

Smoking is considered to be a significant risk factor for the development of postoperative complications after various surgical procedures, mainly by limiting oxygen delivery to tissues. Evidence on the collective impact of smoking in aesthetic procedure outcomes is scarce. The aim of this study is to evaluate the current evidence on the association between smoking and postoperative outcomes in patients who underwent common elective procedures in plastic surgery.

METHODS

PubMed and Cochrane bibliographical databases were searched from January 1950 to October 2016 for studies reporting on patients who underwent facelift, abdominoplasty, breast reduction and breast reconstruction and for studies with included data on smoking history of treated patients.

RESULTS

Fifty-three studies reporting on postoperative complications in tobacco users undergoing facelift, abdominoplasty, breast reduction and reconstruction were identified. Tobacco use is found to significantly increase the total number of postoperative complications as far as abdominoplasty (OR: 5.43; 95% CI = 2.92-10.10), breast reduction (OR: 2.36; 95% CI = 1.64-3.39) and breast reconstruction (OR: 1.91; 95% CI = 1.69-2.17) are concerned. Smoking history does not significantly affect total postoperative complications after facelift procedures (OR: 3.36; 95% CI = 0.92-12.30).

CONCLUSIONS

Smoking predisposes to surgical site infections, delayed wound healing and skin necrosis in patients undergoing the most common aesthetic procedures in plastic surgery. More rigorous and detailed reporting on the history of tobacco use and surgical outcomes following plastic surgery procedures is needed to better quantify the impact of smoking on the overall postoperative care for this patient population.

Is chronic postsurgical pain surgery-induced? A study of persistent postoperative pain following breast reconstruction

BACKGROUND

Chronic postsurgical pain (CPSP) is a reported risk for women undergoing breast reconstruction, but it remains unclear that such persistent pain is induced by reconstructive surgery. To address this concern, this prospective cohort study examined the prevalence of and risk factors associated with CPSP among women undergoing breast reconstruction.

MATERIALS AND METHODS

Women (n = 1996) recruited for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were assessed preoperatively and at two-years postoperatively for relevant medical/.surgical variables, pain experience, body physical well-being, anxiety, depression, and reconstruction procedure type and characteristics.

RESULTS

Nearly half of the entire sample reported some level of preoperative pain. At two years there were statistically significant but not clinically meaningful increases in both pain intensity and chest/upper body discomfort but a decrease in affective pain rating. Average clinical pain severity was strikingly similar for preoperative and postoperative assessments. Preoperative levels of pain, acute postoperative pain, and (marginally) level of depression held consistent relationship at two-year follow-up with all outcome measures. Autologous flap reconstruction was associated with more severe CPSP compared to TE/I reconstruction. Older age, higher BMI, bilateral reconstruction, and adjuvant radiation and chemotherapy were associated with CPSP and chest/upper body discomfort for at least one outcome measure at two years.

CONCLUSIONS

The substantial rate of preoperative pain and comparable prevalence of preoperative and postoperative pain ratings suggest that persistent pain after breast reconstruction may not necessarily reflect surgery-induced pain. Future research will need to determine those factors that contribute to long-term pain following breast reconstruction.

Can weight gain be prevented in women receiving treatment for breast cancer? A systematic review of intervention studies

BACKGROUND

Obesity and weight gain have been associated with poor disease-specific and health-related outcomes in women with breast cancer.

OBJECTIVES

This review aimed to evaluate the effectiveness of weight gain prevention interventions among women with breast cancer.

METHODS

Completed and ongoing trials evaluating a behaviourally based dietary intervention with or without physical activity and with a focus on weight gain prevention during treatment for breast cancer were reviewed. Weight change and body composition data were extracted. Within-group weight change of ±1 kg and between-group (intervention versus control) weight difference of ≥2 kg were defined as successful weight gain prevention.

RESULTS

Five completed trials (seven intervention arms) and five ongoing trials were identified. Completed trials exclusively recruited premenopausal or premenopausal and postmenopausal women. Within-group weight gain was prevented in two intervention arms, two arms achieved weight loss and three arms reported weight gain. Of the five comparisons with control groups, two reported significant differences in weight change between groups. Ongoing trials will provide further evidence on longer-term outcomes, cost-effectiveness and blood markers.

CONCLUSION

This small but growing number of studies provides preliminary and promising evidence that weight gain can be prevented in women with breast cancer undergoing chemotherapy.

Breast reconstruction with anatomical implants: A review of indications and techniques based on current literature

One important modality of breast cancer therapy is surgical treatment, which has become increasingly less mutilating over the last century. Breast reconstruction has become an integrated part of breast cancer treatment due to long-term psychosexual health factors and its importance for breast cancer survivors. Both autogenous tissue-based and implant-based reconstruction provides satisfactory reconstructive options due to better surgeon awareness of "the ideal breast size", although each has its own advantages and disadvantages. An overview of the current options in breast reconstruction is presented in this article.

Patient determinants as independent risk factors for postoperative complications of breast reconstruction

BACKGROUND

Breast reconstruction is an essential component in the treatment of breast cancer. Postoperative complications after breast reconstruction are common and affect patient satisfaction. Determining independent risk factors using patient characteristics could be advantageous for patient assessment and counseling.

METHODS

We retrospectively enrolled 623 consecutive patients who underwent reconstruction with a deep inferior epigastric perforator flap (DIEP), latissimus dorsi flap (LD), lateral thoracodorsal flap (LTDF), or tissue expander with a secondary implant (EXP) in this study. Information on demographic and perioperative factors was collected, as well as information on all postoperative complications. Logistic regression was used to analyze associations between possible patient-related risk factors and postoperative complications.

RESULTS

Smoking was associated with the highest number of early overall complications [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.25-3.37, P=0.0005], followed by body mass index (BMI) (OR 1.07, 95% CI 1.01-1.13, P=0.017). High BMI was associated with the highest number of late overall postoperative complications (OR 1.06, 95% CI 1.00-1.11, P=0.042), followed by history of radiotherapy (OR 1.66, 95% CI 1.01-2.74, P=0.046). When the risk factors were combined, the risk for postoperative complications rose exponentially.

CONCLUSIONS

Our results provide evidence that patients should cease smoking and overweight patients should lose weight before undergoing breast reconstruction. Additionally, if the patient has received radiotherapy, the reconstruction method should be carefully chosen. High BMI, history of radiotherapy, and smoking are independent risk factors for many types of both early and late postoperative complications in breast reconstructive surgery. Combining these risk factors multiplies the risk of postoperative complications.

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

Preoperative Radiotherapy Is Not Associated with Increased Post-mastectomy Short-term Morbidity: Analysis of 77,902 Patients

Supplemental Digital Content is available in the text.

Background:

Neoadjuvant radiotherapy (NRT) enhances breast-conserving surgery outcomes, reducing local recurrence of breast cancer and increasing median survival. However, its effect on postoperative morbidity remains under-studied. We sought to assess the impact of NRT on 30-day postoperative morbidity after mastectomy.

Methods:

We analyzed data from women undergoing mastectomy (with or without immediate reconstruction) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 2005–2011 datasets. ACS-NSQIP is a prospective, risk-adjusted, outcomes-based registry. Data included demographic and perioperative factors. Outcomes studied included surgical site (wound and prosthesis/flap complications), systemic (cardiac, respiratory, neurological, urinary, and venous thromboembolism events), and overall morbidity. Logistic regression was used to estimate the unadjusted odds ratio (uOR) and adjusted odds ratio (aOR) between NRT and postoperative 30-day morbidity.

Results:

The study population included 77,902 women, of which 61,039 (78.4%) underwent mastectomy only and 16,863 (21.6%) underwent mastectomy with immediate breast reconstruction. NRT was administered to 266 (0.4%) mastectomy-only and 75 (0.4%) immediate breast reconstruction patients. In the mastectomy-only group, there were no significant differences in the rates of postoperative surgical site morbidity (aOR = 1.41; 95% confidence interval (CI): 0.76–2.63; P = 0.276), systemic morbidity (aOR = 0.72; 95% CI: 0.40–1.26; P = 0.252), and overall morbidity (aOR = 0.85; 95% CI: 0.54–1.33; P = 0.477) between NRT and control groups. Similarly, no significant differences were found for these three outcomes in the immediate breast reconstruction population. Statistical power for every comparison was >80%.

Conclusions:

This study suggests that NRT is not associated with significantly higher 30-day postoperative complications among breast cancer patients undergoing mastectomy with or without immediate breast reconstruction.

An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction

INTRODUCTION

Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT. This offers uniform distribution of standard radiation doses, thereby minimizing radiation-induced changes while maintaining oncologic safety. We present our 8-year experience with the custom bolus approach for PMRT delivery in immediate autologous breast reconstruction.

METHODS

All immediate autologous breast reconstruction patients requiring PMRT after 2006 were treated with the custom bolus approach. Retrospective chart review was performed to compare the postirradiation complications, reconstruction outcomes, and oncologic outcomes of these patients with those of previous patients at our institution who underwent standard bolus, and to historical controls from peer-reviewed literature.

RESULTS

Over the past 10 years, of the 29 patients who received PMRT, 10 were treated with custom bolus. Custom bolus resulted in fewer radiation-induced skin changes and less skin tethering/fibrosis than standard bolus (0% vs 10% and 20% vs 35%, respectively), and less volume loss and contour deformities compared with historical controls (10% vs 22.8% and 10% vs 30.7%, respectively).

CONCLUSIONS

Custom bolus PMRT minimizes radiation delivery to the internal mammary vessels, anastomoses, and skin; uniformly doses the surgical incision; and provides the necessary radiation dose to prevent recurrence. Because custom bolus PMRT may reduce the deleterious effects of radiation on reconstructive outcomes while maintaining safe oncologic results, we encourage all plastic surgeons to collaborate with radiation oncologists to consider this technique.

Blood loss and duration of surgery are independent risk factors for complications after breast reconstruction

BACKGROUND

Complications after breast reconstructive surgery are common, and they can be caused by a wide range of factors. The aim of the present study was to identify independent perioperative risk factors for postoperative complications after breast reconstruction.

METHODS

A retrospective study was performed of 623 consecutive breast cancer patients who had undergone deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) flap, lateral thoracodorsal flap (LTDF), or tissue expander with secondary implant (EXP). Data on demography, perioperative parameters, and complications were collected. Logistic regression models adjusted to the reconstruction method and to confounding demographic factors were used for statistical analysis.

RESULTS

Increased blood loss for each 10-ml step increased the risk for overall early complications (p = 0.017), early seroma (p = 0.037), early resurgery (p = 0.010), late local overall complications (p = 0.024), and late fat necrosis (p = 0.031). Longer duration of surgery for each 10-minute step increased the risk of overall early complications (p = 0.019), but, in the univariate model, there was an increased risk for nine different types of complications (p = 0.004-0.029). There was no association between the experience of the surgeon performing the procedure and the frequency of complications.

CONCLUSIONS

Duration of surgery and blood loss during surgery are independent risk factors for postoperative complications, and should be minimised. Further research is needed to establish the association between the experience of the surgeon and the occurrence of complications.

Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications

INTRODUCTION

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.

METHODS

Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.

RESULTS

Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).

CONCLUSION

Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A3 online Instructions to Authors. www.springer.com/00266 .