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Wen YE, Steppe C, Teotia SS, Haddock NT. Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction. J Reconstr Microsurg 2024; 40:217-226. [PMID: 37467772 DOI: 10.1055/a-2133-1018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. METHODS Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. RESULTS Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). CONCLUSION Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.
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Affiliation(s)
- Y Edward Wen
- University of Texas Southwestern Medical Center, Medical School, Dallas, Texas
| | - Cyrus Steppe
- University of Texas Southwestern Medical Center, Medical School, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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2
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Herieka M, Amin K, Kosutic D. An Unexpected Late Recurrence of Breast Irradiation-Induced Angiosarcoma Following Autologous Microvascular Breast Reconstruction. Cureus 2024; 16:e54741. [PMID: 38524062 PMCID: PMC10960949 DOI: 10.7759/cureus.54741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
The authors present the case of a 68-year-old female who developed recurrent angiosarcoma, a rare but recognized complication after breast irradiation therapy in the treatment of breast cancer. Microvascular breast reconstruction was performed after the completion of 10 years of disease-free clinical surveillance. Abdominal tissue was harvested and transferred onto the chest wall with restoration of its blood supply using microsurgical techniques to recreate the breast. Unexpectedly, local recurrence of irradiation-induced angiosarcoma was confirmed in the reconstructed breast 12 years later, a unique finding, given the long latent period and recruitment of tissues from a distant site. It is vital to consider the potential of late recurrence before embarking on complex reconstructions, and this should be discussed with patients who have a history of angiosarcoma. This further emphasizes the importance of long-term surveillance in such a rare, yet aggressive tumor at specialist centers.
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Affiliation(s)
- Mohammed Herieka
- Plastic and Reconstructive Surgery, The Christie NHS Foundation Trust, Manchester, GBR
| | - Kavit Amin
- Plastic and Reconstructive Surgery, The Christie NHS Foundation Trust, Manchester, GBR
| | - Damir Kosutic
- Plastic and Reconstructive Surgery, The Christie NHS Foundation Trust, Manchester, GBR
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Hansson E, Brorson F, Löfstrand J, Elander A, Svensson M. Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction. J Plast Surg Hand Surg 2024; 59:1-13. [PMID: 38189784 DOI: 10.2340/jphs.v59.19649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies. METHODS Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting. RESULTS AND CONCLUSIONS A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Fredrik Brorson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Jonas Löfstrand
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA; School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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4
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Johnson L, White P, Jeevan R, Browne J, Gulliver-Clarke C, O’Donoghue J, Mohiuddin S, Hollingworth W, Fairbrother P, MacKenzie M, Holcombe C, Potter S. Long-term patient-reported outcomes of immediate breast reconstruction after mastectomy for breast cancer: population-based cohort study. Br J Surg 2023; 110:1815-1823. [PMID: 37766501 PMCID: PMC10638530 DOI: 10.1093/bjs/znad276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/27/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Breast reconstruction is offered to improve quality of life for women after mastectomy for breast cancer, but information regarding the long-term patient-reported outcomes of different reconstruction procedures is currently lacking. The Brighter study aimed to evaluate long-term patient-reported outcomes after immediate breast reconstruction (IBR) in a population-based cohort. METHODS Women who underwent mastectomy with IBR for breast cancer in England between 1 January 2008 and 31 March 2009 were identified from National Health Service Hospital Episode Statistics. Surviving women were invited to complete the BREAST-Q, EQ-5D-5L™, and ICECAP-A at least 12 years after the index procedure. Questionnaires were scored according to developers' instructions and compared by IBR type. RESULTS Some 1236 women underwent IBR; 343 (27.8 per cent) had 2-stage expander/implant, 630 (51.0 per cent) latissimus dorsi, and 263 (21.3 per cent) abdominal flap reconstructions, with a mean(s.d.) follow-up of 13.3(0.5) years. Women who underwent abdominal flap reconstruction reported higher scores in all BREAST-Q domains than those who had other procedures. These differences remained statistically significant and clinically meaningful after adjusting for age, ethnicity, geographical region, socioeconomic status, smoking, BMI, and complications. The greatest difference was seen in scores for satisfaction with breasts; women who had abdominal flap reconstructions reported scores that were 13.17 (95 per cent c.i. 9.48 to 16.87) points; P < 0.001) higher than those among women who had two-stage expander/implant procedures. Women who underwent latissimus dorsi reconstruction reported significantly more pain/discomfort on the EQ-5D-5L™, but no other differences between procedures were seen. CONCLUSION Long-term patient-reported outcomes are significantly better following abdominal flap reconstruction than other traditional procedure types. These findings should be shared with women considering IBR to help them make informed decisions about their surgical options.
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Affiliation(s)
- Leigh Johnson
- Translational Health Sciences, Bristol Medical School, Bristol, UK
| | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | - Ranjeet Jeevan
- Department of Plastic Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Carmel Gulliver-Clarke
- Department of Breast Surgery, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
| | - Joe O’Donoghue
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Syed Mohiuddin
- Translational Health Sciences, Bristol Medical School, Bristol, UK
| | | | | | | | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
| | - Shelley Potter
- Translational Health Sciences, Bristol Medical School, Bristol, UK
- Bristol Breast Care Centre, Southmead Hospital, Bristol, UK
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5
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Harmeling JX, Woerdeman LAE, Ozdemir E, Schaapveld M, Oldenburg HSA, Janus CPM, Russell NS, Koppert LB, Krul IM, van Leeuwen FE, Mureau MAM. Surgical outcomes following breast reconstruction in patients with and without a history of chest radiotherapy for Hodgkin lymphoma: a multicentre, matched cohort study. Int J Surg 2023; 109:2896-2905. [PMID: 37037583 PMCID: PMC10583922 DOI: 10.1097/js9.0000000000000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/12/2022] [Indexed: 04/12/2023]
Abstract
BACKGROUND Breast cancer is the most common treatment-related second malignancy among women with previous chest radiotherapy for Hodgkin lymphoma (HL). Little is known about the effects of this kind of radiotherapy on the outcomes of postmastectomy breast reconstruction (BR). This study compared adverse outcomes of BR after HL-related chest radiotherapy to matched controls. METHODS The authors conducted a retrospective, matched cohort study in two expert cancer centres in the Netherlands. BRs after therapeutic or prophylactic mastectomy in HL survivors who received chest radiotherapy were matched with BRs in nonirradiated patients without HL on age at mastectomy date, date of BR, and type of BR. The primary outcome was complication-related BR failure or conversion and secondary outcomes were complication-related re-operation, capsular contracture, major donor-site complications, and complication-related ICU admission. The authors analyzed all outcomes univariably using Fisher's exact tests and the authors assessed reconstruction failure, complication-related re-operation, and capsular contracture with multivariable Cox regression analysis adjusting for confounding and data clustering. RESULTS Seventy BRs in 41 patients who received chest radiotherapy for HL were matched to 121 BRs in 110 nonirradiated patients. Reconstruction failure did not differ between HL survivors (12.9%) and controls (12.4%). The comparison groups showed no differences in number of reoperations, major donor-site complications, or capsular contractures. BR in HL survivors more often let to ICU admission due to complications compared with controls ( P =0.048). CONCLUSIONS We observed no increased risk of adverse outcomes following BR after previous chest radiotherapy for HL. This is important information for counselling these patients and may improve shared decision-making.
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Affiliation(s)
| | | | - Ezgi Ozdemir
- Departments of Plastic and Reconstructive Surgery
| | - Michael Schaapveld
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Cécile P M Janus
- Radiation Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam
| | | | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC, Rotterdam
| | - Inge M Krul
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Dunson B, Kogan S, Grosser JA, Davidson A, Llull R. Influence of Closed-incision Negative Pressure Wound Therapy on Abdominal Site Complications in Autologous Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5326. [PMID: 37817928 PMCID: PMC10561809 DOI: 10.1097/gox.0000000000005326] [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: 06/04/2023] [Accepted: 08/24/2023] [Indexed: 10/12/2023]
Abstract
Background Closed-incision negative pressure wound therapy (ciNPWT) has shown promise in reducing surgical wound complications. Among its numerous benefits, it allows for exudate management and tension offloading from wound edges. The purpose of this systematic review and meta-analysis was to assess the efficacy of prophylactic ciNPWT versus conventional dressings on abdominal donor site complications in microsurgical breast reconstruction (MR). Methods A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in January 2023. PubMed and Embase were searched to identify all relevant studies. Data collected included rates of total wound complications, wound dehiscence, infection, seroma, and length of hospital stay. Results A total of 202 articles were screened, and eight studies (1009 patients) met the inclusion criteria. Use of ciNPWT was associated with a significantly lower rate of wound dehiscence (OR, 0.53; 95% confidence interval, 0.33-0.85; P = 0.0085, I2 = 0%). There was no significant difference in the rate of total wound complications [odds ratio (OR), 0.63; 95% CI, 0.35-1.14; P = 0.12, I2 = 69%], donor site infection (OR, 0.91; 95% CI, 0.42-1.50; P = 0.47, I2 = 13%), seroma (OR, 0.74; 95% CI, 0.22-2.49; P = 0.63, I2 = 57%), or length of hospital stay (SMD, 0.089; 95% CI, -0.13-0.35; P = 0.37, I2 = 29%). Conclusions Although exudate management by ciNPWT fails to reduce surgical site infection, seroma formation, and overall length of stay, ciNPWT tension offloading properties seem to be associated with lower rates of wound dehiscence when compared with conventional dressings in abdominal-based autologous breast reconstruction.
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Affiliation(s)
- Blake Dunson
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Samuel Kogan
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Joshua A. Grosser
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Amelia Davidson
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Ramon Llull
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
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7
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Cheng S, Wang A, Ding H, Ding J, Wang L, Gao W. High-pressure infusion improves multi-territory perforator flap viability via choke artery dilation: A preliminary study in a rat model. J Plast Reconstr Aesthet Surg 2023; 84:505-513. [PMID: 37418849 DOI: 10.1016/j.bjps.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/25/2023] [Accepted: 06/05/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Multi-territory perforator flaps have become the preferred option for the repair and reconstruction of large soft tissue defects. Although methods (e.g., pharmacological agents, mechanical stimulation, and thermal stimulation) were developed to open choke vessels to improve flap survival, the flap necrosis rate is still as high as 28.8%. The authors hypothesized that high-pressure infusion might enhance flap viability by dilating choke arteries intraoperatively in a rat model of multi-territory perforator flap. METHODS Two-month-old male Sprague-Dawley rats were randomized into two groups (n = 32 each). During the multi-territory perforator flap elevation based on the right superficial epigastric angiosome, one group received continuous high-pressure infusion (mean pressure, 250 mmHg; duration, 1 min) of an isotonic heparin sodium solution (12,500 U/L) via the artery in the pedicle, whereas the other group received no infusion. At 7 days postoperatively, arteriography was performed; endothelial nitric oxide synthase (eNOS) and vascular endothelial growth factor (VEGF) expression and microvascular density were evaluated by western blot and histology, respectively; and flap survival was compared. Moreover, intraluminal diameters were examined at 1 day and 7 days postoperatively using hematoxylin and eosin staining, and coagulation function was assessed immediately postoperatively. RESULTS High-pressure infusion significantly promoted the dilation of choke arteries at 1 day and 7 days postoperatively. It also increased eNOS and VEGF expression, flap survival, and microvascular density. The coagulation function remained unaffected. CONCLUSIONS High-pressure infusion allowed intraoperative and postoperative dilation of the choke arteries that enhanced the viability of multi-territory perforator flaps in rats.
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Affiliation(s)
- Sheng Cheng
- Department of Orthopaedics, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China; Department of Orthopedics, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, Zhejiang 325000, China; Department of Second Clinical Medical, the Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Anyuan Wang
- Department of Orthopaedics, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China; Department of Orthopedics, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, Zhejiang 325000, China
| | - Hongfeng Ding
- Department of Orthopaedics, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China; Department of Orthopedics, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, Zhejiang 325000, China; Department of Second Clinical Medical, the Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jian Ding
- Department of Orthopaedics, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China; Department of Orthopedics, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, Zhejiang 325000, China
| | - Long Wang
- Department of Orthopaedics, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China; Department of Orthopedics, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, Zhejiang 325000, China
| | - Weiyang Gao
- Department of Orthopaedics, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China; Department of Orthopedics, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, Zhejiang 325000, China.
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8
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Koesters EC, Chang DW. Radiation and free flaps: what is the optimal timing? Gland Surg 2023; 12:1122-1130. [PMID: 37701302 PMCID: PMC10493623 DOI: 10.21037/gs-23-154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 08/09/2023] [Indexed: 09/14/2023]
Abstract
The debate over when to perform flaps in patients undergoing radiation remains an ongoing dilemma without definitive resolution. Classically, reconstructive surgeons recommended avoiding exposure of autologous flaps to radiotherapy due to concerns over surgical complications and poor aesthetic outcomes. However, delayed reconstruction carries its own risk profile and aesthetic limitations, given the irreversible changes to the breast envelope. Immediate reconstruction not only confers psychosocial benefits but allows for preservation of the native breast skin and footprint. In recent years, a growing body of evidence suggests that with modern radiation techniques, long-term outcomes of immediate vs. delayed autologous reconstruction may be more similar than previously thought. This review examines the advantages and disadvantages of each treatment algorithm and critically evaluates the existing literature on autologous breast reconstruction in the setting of post-mastectomy radiotherapy. Importantly, radiation regimens have varied widely over time and between institutions, introducing significant heterogeneity in published outcomes of flap contracture or fat necrosis after immediate reconstruction. While delayed autologous reconstruction remains a reasonable pathway, the benefits of immediate reconstruction should not be dismissed. Our findings ultimately corroborate the view that immediate flap reconstruction is a sound treatment option that can be safely offered to patients. The decision regarding which pathway to pursue should ultimately be patient-centric and driven by multidisciplinary consensus, rather than by prior dogma.
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Affiliation(s)
- Emma C Koesters
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - David W Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
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9
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Chun Fat S, Ray E. Gender-affirming microvascular breast reconstruction. Gland Surg 2023; 12:982-988. [PMID: 37727344 PMCID: PMC10506111 DOI: 10.21037/gs-23-133] [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: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 09/21/2023]
Abstract
Gender-affirming surgery (GAS), including breast feminization, is requested and performed with increasing frequency. Transgender women may seek chest feminization surgery to address gender dysphoria, and such procedures have been shown to increase psychosocial and sexual well-being. Despite the potential effects of hormone therapy and androgen blockade on breast development, the results of glandular growth in adult transgender women are typically disappointing and are often inadequate to achieve the patient's goals. When evaluating options for breast construction, an implant-based approach meets the needs of most patients. However, patient choice, implant complications, acquired and congenital alterations of chest anatomy and the unique challenges of feminizing a natal male chest occasionally require consideration of other options. We review the few cases of gender-affirming breast reconstruction using autologous tissue published in the literature and summarize the senior author's approach and technique. We also review two cases of autologous chest feminization by the senior author. Ultimately, while implant-based reconstruction should continue to be the default procedure and offered to the majority of patients, several factors need to be considered when determining the optimal approach to breast feminization for a given patient. In patients with congenital or acquired deformities or a variety of factors where a reasonable outcome cannot be achieved with implants, autologous reconstruction should remain an option.
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Affiliation(s)
- Shelby Chun Fat
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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10
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Piatkowski AA, Wederfoort JLM, Hommes JE, Schop SSJ, Krastev TK, van Kuijk SMJ, van der Hulst RRWJ. Effect of Total Breast Reconstruction With Autologous Fat Transfer Using an Expansion Device vs Implants on Quality of Life Among Patients With Breast Cancer: A Randomized Clinical Trial. JAMA Surg 2023; 158:456-464. [PMID: 36857058 PMCID: PMC9979010 DOI: 10.1001/jamasurg.2022.7625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/15/2022] [Indexed: 03/02/2023]
Abstract
Importance There is a need for a new, less invasive breast reconstruction option for patients who undergo mastectomy in their breast cancer treatment. Objective To investigate quality of life (QoL) among patients undergoing a new breast reconstruction technique, autologous fat transfer (AFT), compared with that among patients undergoing implant-based reconstruction (IBR). Design, Setting, and Participants The BREAST trial was a randomized clinical trial conducted between November 2, 2015, and October 31, 2021, performed in 7 hospitals across the Netherlands. Follow-up was 12 months. Referrals could be obtained from general practitioners and all departments from participating or nonparticipating hospitals. The patients with breast cancer who had undergone mastectomy and were seeking breast reconstruction were screened for eligibility (radiotherapy history and physique) by participating plastic surgeons. Patients receiving postmastectomy radiotherapy were excluded. Interventions Breast reconstruction with AFT plus expansion or 2-phased IBR. Randomization was done in a 1:1 ratio. Main Outcomes and Measures The statistical analysis was performed per protocol. The predefined primary outcome was QoL at 12 months after final surgery. This was measured by the BREAST-Q questionnaire, a validated breast reconstruction surgery questionnaire. Questions on the BREAST-Q questionnaire are scored from 0 to 100, with a higher score indicating greater satisfaction or better QoL (depending on the scale). Secondary outcomes were breast volume and the safety and efficacy of the techniques. Results A total of 193 female patients (mean [SD] age, 49.2 [10.6] years) 18 years or older who desired breast reconstruction were included, of whom 91 patients in the AFT group (mean [SD] age, 49.3 [10.3] years) and 80 in the IBR group (mean age, 49.1 [11.0] years) received the allocated intervention. In total, 64 women in the AFT group and 68 women in the IBR group completed follow-up. In the IBR group, 18 patients dropped out mainly due to their aversion to implant use while in the AFT group 6 patients ended their treatment prematurely because of the burden (that is, the treatment being too heavy or tiring). The BREAST-Q scores were higher in the AFT group in all 5 domains and significantly higher in 3: satisfaction with breasts (difference, 9.9; P = .002), physical well-being: chest (difference; 7.6; P = .007), and satisfaction with outcome (difference, 7.6; P = .04). Linear mixed-effects regression analysis showed that QoL change over time was dependent on the treatment group in favor of AFT. The mean (SD) breast volume achieved differed between the groups (AFT: 300.3 [111.4] mL; IBR: 384.1 [86.6] mL). No differences in oncological serious adverse events were found. Conclusions and Relevance This randomized clinical trial found higher QoL and an increase in QoL scores over time in the AFT group compared with the IBR group. No evidence was found that AFT was unsafe. This is encouraging news since it provides a third, less invasive reconstruction option for patients with breast cancer. Trial Registration ClinicalTrials.gov Identifier: NCT02339779.
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Affiliation(s)
- Andrzej A. Piatkowski
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, VieCuri Medical Center, Venlo, the Netherlands
| | - Jamilla L. M. Wederfoort
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Juliette E. Hommes
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Sander S. J. Schop
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Todor K. Krastev
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Sander M. J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - René R. W. J. van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
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Abdominoplasty and Breast Augmentation with Outpatient Cosmetic Deep Inferior Epigastric Perforator Flaps. Plast Reconstr Surg 2023; 151:234e-240e. [PMID: 36354968 DOI: 10.1097/prs.0000000000009836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The authors describe the use of deep inferior epigastric perforator (DIEP) flaps in outpatient cosmetic breast augmentation. METHODS The authors reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. All patients underwent an early recovery protocol including microfascial incisions to harvest the DIEP flaps and rib preservation in addition to early recovery after surgery protocols with intraoperative anesthetic blocks. RESULTS Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients reported preoperative dissatisfaction with their abdomen and breasts. Microfascial incisions for single perforator abdominal flaps ( n = 17) averaged 1.7 cm (range, 1.3 to 2.4 cm) and flaps with multiple perforators ( n = 5) averaged 2.4 cm (range, 2 to 2.5 cm). Dissection of recipient internal mammary artery vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses, major complications, or take-backs were reported. CONCLUSIONS Patients who desire abdominoplasty and augmentation are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. The early recovery protocol allows the surgeon to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with excellent results and no total or partial flap losses, offsetting the high costs associated with the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Gallo L, Chu JJ, Shamsunder MG, Hatchell A, Patel A, Godwin K, Hernandez M, Pusic AL, Nelson JA, Voineskos SH. Best Practices for BREAST-Q Research: A Systematic Review of Study Methodology. Plast Reconstr Surg 2022; 150:526e-535e. [PMID: 35749737 PMCID: PMC9805659 DOI: 10.1097/prs.0000000000009401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Data heterogeneity and methodologic errors hinder the ability to draw clinically meaningful conclusions from studies using the BREAST-Q Reconstruction Module patient-reported outcome measure. In this systematic review, the authors evaluate the quality of BREAST-Q Reconstruction Module administration in relation to the BREAST-Q version 2.0 user's guide and the reporting of key methodology characteristics. The authors also describe a framework for improving the quality of BREAST-Q data analysis and reporting. METHODS The authors conducted a systematic search of PubMed, Embase, Cochrane CENTRAL, and Ovid HAPI databases to identify articles on the BREAST-Q Reconstruction Module to assess postmastectomy breast reconstruction outcomes. The authors registered the protocol before study implementation on Open Science Framework ( https://osf.io/c5236 ) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on mode of BREAST-Q administration, time horizon justification, and sample size calculation were collected. RESULTS The authors included 185 studies in the analysis. Errors in BREAST-Q administration were identified in 36 studies (19.5 percent). Appropriate administration of the BREAST-Q could not be determined in 63 studies (34.1 percent) because of insufficient reporting. Time horizon for the primary outcome was reported in 71 studies (38.4 percent), with only 17 (9.2 percent) reporting a sample size calculation. CONCLUSIONS The authors identified important yet actionable shortcomings in the BREAST-Q literature. Researchers are encouraged to review the BREAST-Q user's guide in the study design phase to mitigate errors in patient-reported outcome measure administration and reporting for future trials using the BREAST-Q Reconstruction Module. Adhering to these guidelines will allow for greater clinical utility and generalizability of BREAST-Q research.
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Affiliation(s)
- Lucas Gallo
- Division of Plastic Surgery, McMaster University, Hamilton, ON, Canada
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meghana G. Shamsunder
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Aadit Patel
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kendra Godwin
- Medical Library, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marisol Hernandez
- Medical Library, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea L. Pusic
- Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sophocles H. Voineskos
- Division of Plastic Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
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13
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Nelson JA, Shamsunder MG, Myers PL, Polanco TO, Coriddi MR, McCarthy CM, Matros E, Dayan JH, Disa JJ, Mehrara BJ, Pusic AL, Allen RJ. Matched Preliminary Analysis of Patient-Reported Outcomes following Autologous and Implant-Based Breast Reconstruction. Ann Surg Oncol 2022; 29:5266-5275. [PMID: 35366702 PMCID: PMC9253052 DOI: 10.1245/s10434-022-11504-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/07/2022] [Indexed: 08/03/2023]
Abstract
BACKGROUND Comparisons of autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR) involve unavoidable confounders, which are often adjusted for in post hoc regression analyses. This study compared patient-reported outcomes between ABR patients and IBR patients by using propensity score matching to control for confounding variables upfront. METHODS Propensity score matching analysis (2:1 nearest-neighbor matching with replacement) was performed for patients who underwent ABR or IBR without radiotherapy. Matched covariates included age, body mass index, history of psychiatric diagnosis, race-ethnicity, smoking status, and laterality of reconstruction. Outcomes of interest were BREAST-Q questionnaire scores for breast satisfaction and well-being. RESULTS Of the 2334 patients identified, 427 were included in the final analysis: 159 who underwent ABR and 268 who underwent IBR. The ABR group matched the IBR group in the selected characteristics. ABR patients did not differ significantly from IBR patients in breast satisfaction or well-being at either 1 or 2 years after reconstructive surgery. CONCLUSIONS This preliminary analysis of immediate breast reconstruction patients not requiring radiation therapy with similar propensities for ABR or IBR suggests comparable levels of breast satisfaction and well-being within 2 years after reconstructive surgery. Further research is needed with larger sample sizes, statistical power, and follow-up to better understand patient reported outcomes in this population, as the current findings differ from studies where patients were not matched on baseline characteristics.
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Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Meghana G Shamsunder
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paige L Myers
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thais O Polanco
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle R Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Colleen M McCarthy
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph J Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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The iTOP trial: Comparing immediate techniques of oncoplastic surgery with conventional breast surgery in women with breast cance - A prospective, controlled, single-center study. Int J Surg 2022; 104:106694. [PMID: 35662621 PMCID: PMC10084682 DOI: 10.1016/j.ijsu.2022.106694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/02/2022] [Accepted: 05/22/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Oncoplastic techniques allow resection of larger tumors, permitting breast conservation in cases otherwise requiring mastectomy. We sought to prospectively compare quality of life (QoL) in patients undergoing oncoplastic surgery as compared to conventional breast conservation (CBC) or mastectomy is lacking. METHODS Patients diagnosed with BIRADS IV-VI lesion were eligible if resection of ≥10% of the breast volume was planned. Patients were allowed to decide whether they wanted to undergo CBC or oncoplastic breast conservation (OBC). Patients who underwent mastectomy and immediate breast reconstruction (IBR) were also included for comparison. The primary endpoint was breast self-esteem using the Breast Image Scale (BIS) at 12 months, secondary endpoints were perioperative morbidity and QoL using the BREAST-Q questionnaire. RESULTS From 2011 to 2016, 205 patients were included in the study. 116 patients (56.6%) received CBC, 46 (22.4%) OBC and 43 (21%) MIBR. Women in the OBC group were more likely to have tumors ≥ 2cm than those in the CBC group (34.7% vs. 17.5%, respectively). Women who underwent MIBR were more likely to have tumors > 5cm than those in the CBC and OBC groups (23% vs 1% and 10%, respectively). The BIS and BREAST-Q improved in each group after 12 months but did not differ significantly between groups at any time point. Surgical complications (seroma, bleeding, infection, necrosis) were numerically more likely in the OBC and MIBR groups. CONCLUSION OBC and the MIBR allow for resection of larger tumors with a similar quality of life as CBC.
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15
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Makki A, Thomsen JB, Gunnarsson GL, Hölmich PLR, Sørensen PJA, Rindom MB. A cost-effectiveness analysis of delayed breast reconstruction with pedicled flaps from the back. J Plast Reconstr Aesthet Surg 2022; 75:2211-2218. [PMID: 35365412 DOI: 10.1016/j.bjps.2022.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 02/05/2022] [Accepted: 02/15/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Variability in breast reconstruction methods provides an opportunity to investigate whether a method is superior to another with regard to cost, quality, or both. We performed a cost-effectiveness analysis (CEA) study based on tertiary endpoint data from a randomized clinical trial to compare the cost-effectiveness of delayed breast reconstruction by either a latissimus dorsi flap (LD) or a thoracodorsal artery perforator flap (TAP). MATERIAL & METHODS A total of 50 women were included for unilateral delayed breast reconstruction and were randomized to reconstruction by either the LD flap (n = 18) or the TAP flap (n = 22). The CEA was based on differences in shoulder function after the reconstruction. Direct and indirect costs relating to the two procedures were assessed by the Danish Diagnosis-Related Groups tariffs. RESULTS Our analysis showed a significant positive effect of introducing the TAP flap on the total shoulder score with an additional cost of $2779. The incremental cost-effectiveness ratio was $4481 and based on a willingness to pay (WTP) $500, we found an estimated net benefit of $519, which was statistically significant (p = 0.0375). The cost-effectiveness acceptability curve indicated that there is a 96.3% probability for the TAP flap being cost-effective to the LD flap at a WTP threshold of $500. CONCLUSION From a societal perspective, our cost-effective analysis demonstrated that the TAP flap is the more cost-effective method of breast reconstruction compared to the LD flap with respect to patient-reported shoulder-related disability.
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Affiliation(s)
- Ahmad Makki
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark.
| | - Jørn B Thomsen
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark; Research Unit for Plastic Surgery, Odense University Hospital, University of Southern, Odense, Denmark
| | | | - Professor Lisbet R Hölmich
- Department of Plastic Surgery, Herlev & Gentofte Hospital, Herlev, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Professor Jens A Sørensen
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark; Research Unit for Plastic Surgery, Odense University Hospital, University of Southern, Odense, Denmark
| | - Mikkel B Rindom
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
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16
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Dejean MF, Dabi Y, Goutard M, Taveau CB, Lantieri LA, Lellouch AG. Deep inferior epigastric perforator free flap in elderly women for breast reconstruction: The experience of a tertiary referral center and a literature review. Breast J 2021; 27:700-705. [PMID: 34258820 DOI: 10.1111/tbj.14273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND A general belief is to consider elderly patients as poor candidates for free flap reconstruction, which does not reflect our 20-year experience for breast reconstruction (BR). The aim of this study was to determine the safety and benefits of BR using deep inferior epigastric perforator (DIEP) free flap in the elderly population. METHODS We conducted a retrospective study of all consecutive BRs using DIEP flaps in patients 65 years or older at the European Georges Pompidou Hospital from January 2011 to December 2019. Postoperative complications were reported as minor or major. We used a descriptive approach to analyze the main characteristics of the patients included. Surgical patient-reported outcomes and quality of life were assessed using the validated BREAST-Q questionnaire. RESULTS Eighty-three DIEP flaps were performed in 79 patients (4 bilateral flaps) for BR. Sixty-six percent of the patients (52/79) did not present any complication. Total flap loss occurred in 3 BR (3.6%), arterial thrombosis in 4 BR (4.8%), and venous thrombosis in 8 BR (9.6%). The average duration of inpatient stay was 9.5 (±2.7) days. Forty-one of 69 eligible patients completed the questionnaire (response rate 59.4%). Patients reported high satisfaction and well-being scores. The mean Q score for psychosocial well-being was 75.4 (±16.7) and 59 (±13.3) for satisfaction with breasts. CONCLUSION In our retrospective cohort, DIEP flap BR in elderly population had similar success and complication rates compared with those in younger patients, as well as high satisfaction scores. The free flap should be encouraged for BR in women over 65 years of age, and personal motivation as well as physiological age considered as main criteria for patient selection.
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Affiliation(s)
- Marie F Dejean
- Department of Plastic Surgery, Angers Hospital, University of Angers, Paris, France
| | - Yohann Dabi
- Department of Obstetrics and Gynecology and Reproductive Medicine, Tenon Hospital, AP - HP, Sorbonne University, Paris, France
| | - Marion Goutard
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris, Paris, France.,Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Department of Plastic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.,Shriners Hospitals for Children, Boston, MA, USA
| | - Corentin B Taveau
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris, Paris, France
| | - Laurent A Lantieri
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris, Paris, France
| | - Alexandre G Lellouch
- Department of Plastic Surgery, European George Pompidou Hospital, University of Paris, Paris, France.,Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA.,Department of Plastic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.,Shriners Hospitals for Children, Boston, MA, USA
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17
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Discussion: Understanding the Relationship between Breast Reconstruction Subtype and Risk of Financial Toxicity: A Single-Institution Pilot Study. Plast Reconstr Surg 2021; 148:12e-13e. [PMID: 34181600 DOI: 10.1097/prs.0000000000008113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Heidekrueger PI, Moellhoff N, Horch RE, Lohmeyer JA, Marx M, Heitmann C, Fansa H, Geenen M, Gabka CJ, Handstein S, Prantl L, von Fritschen U. Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany-A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions. J Clin Med 2021; 10:jcm10051016. [PMID: 33801419 PMCID: PMC7958631 DOI: 10.3390/jcm10051016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/20/2022] Open
Abstract
While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.
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Affiliation(s)
- Paul I. Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany
- Correspondence: (P.I.H.); (L.P.); (U.v.F.); Tel.: +49-941-944-6763 (L.P.)
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, 91054 Erlangen, Germany;
| | - Jörn A. Lohmeyer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, 20259 Hamburg, Germany;
| | - Mario Marx
- Department of Plastic, Reconstructive and Breast Surgery, Elbland Hospital Radebeul, 01445 Radebeul, Germany;
| | | | - Hisham Fansa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Breast Centre Spital Zollikerberg, 8125 Zollikerberg, Switzerland;
| | - Matthias Geenen
- Department of Reconstructive Surgery, Lubinus Clinic Kiel, 24106 Kiel, Germany;
| | - Christian J. Gabka
- Nymphenburg Clinic for Plastic and Aesthetic Surgery, 80636 Munich, Germany;
| | - Steffen Handstein
- Department of Plastic, Reconstructive, and Breast Surgery, Municipal Hospital Goerlitz, 02828 Görlitz, Germany;
| | - Lukas Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany
- Correspondence: (P.I.H.); (L.P.); (U.v.F.); Tel.: +49-941-944-6763 (L.P.)
| | - Uwe von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, 14165 Berlin, Germany
- Correspondence: (P.I.H.); (L.P.); (U.v.F.); Tel.: +49-941-944-6763 (L.P.)
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Rocco N, Catanuto G, Chiodini P, Rispoli C, Nava MB. Implants versus autologous tissue flaps for breast reconstruction following mastectomy. Hippokratia 2021. [DOI: 10.1002/14651858.cd013821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nicola Rocco
- G.Re.T.A. Group for Reconstructive and Therapeutic Advancements; Naples Italy
| | - Giuseppe Catanuto
- Multidisciplinary Breast Unit; Azienda Ospedaliera Cannizzaro; Catania Italy
- G.Re.T.A. Group for Reconstructive and Therapeutic Advancements; Catania Italy
| | - Paolo Chiodini
- Physical and Mental Health; University of Campania "Luigi Vanvitelli"; Napoli Italy
| | | | - Maurizio B Nava
- G.Re.T.A. Group for Reconstructive and Therapeutic Advancements; Milan Italy
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20
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Kouwenberg CAE, Mureau MAM, Kranenburg LW, Rakhorst H, de Leeuw D, Klem TMAL, Koppert LB, Ramos IC, Busschbach JJ. Cost-utility analysis of four common surgical treatment pathways for breast cancer. Eur J Surg Oncol 2020; 47:1299-1308. [PMID: 33349523 DOI: 10.1016/j.ejso.2020.11.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/10/2020] [Accepted: 11/20/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim was to evaluate the cost-utility of four common surgical treatment pathways for breast cancer: mastectomy, breast-conserving therapy (BCT), implant breast reconstruction (BR) and autologous-BR. METHODS Patient-level healthcare consumption data and results of a large quality of life (QoL) study from five Dutch hospitals were combined. The cost-effectiveness was assessed in terms of incremental costs and quality adjusted life years (QALYs) over a 10-year follow-up period. Costs were assessed from a healthcare provider perspective. RESULTS BCT resulted in comparable QoL with lower costs compared to implant-BR and autologous-BR and showed better QoL with higher costs than mastectomy (€17,246/QALY). QoL outcomes and costs of especially autologous-BR were affected by the relatively high occurrence of complications. If reconstruction following mastectomy was performed, implant-BR was more cost-effective than autologous-BR. CONCLUSION The occurrence of complications had a substantial effect on costs and QoL outcomes of different surgical pathways for breast cancer. When this was taken into account, BCT was most the cost-effective treatment. Even with higher costs and a higher risk of complications, implant-BR and autologous-BR remained cost-effective over mastectomy. This pleas for adapting surgical pathways to individual patient preferences in the trade-off between the risks of complications and expected outcomes.
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Affiliation(s)
- Casimir A E Kouwenberg
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
| | - Marc A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Leonieke W Kranenburg
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Hinne Rakhorst
- Department of Plastic, Reconstructive and Hand Surgery, Hospital Medisch Spectrum Twente/ Hospital Group Twente, Enschede, the Netherlands
| | - Daniëlle de Leeuw
- Department of Surgery, Hospital Group Twente, Almelo, the Netherlands
| | - Taco M A L Klem
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Isaac Corro Ramos
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jan J Busschbach
- Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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21
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Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3180. [PMID: 33173692 PMCID: PMC7647491 DOI: 10.1097/gox.0000000000003180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
Background Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps. Methods This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed. Results Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants. Conclusions Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.
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22
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Mandelbaum AD, Thompson CK, Attai DJ, Baker JL, Slack G, DiNome ML, Benharash P, Lee MK. National Trends in Immediate Breast Reconstruction: An Analysis of Implant-Based Versus Autologous Reconstruction After Mastectomy. Ann Surg Oncol 2020; 27:4777-4785. [PMID: 32712889 DOI: 10.1245/s10434-020-08903-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/19/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Many factors affect access to immediate breast reconstruction (IR) after mastectomy. The present study was performed to assess trends, outcomes, and predictors of IR techniques using a nationally representative cohort. METHODS The 2009-2014 National Inpatient Sample (NIS) was used to identify adult women who underwent inpatient mastectomy with IR. Patients were compared by type of reconstruction: implant-based IR versus autologous reconstruction (AR). AR was classified as a microsurgical or pedicled flap procedure. Incidence, outcomes, and predictors were assessed using Chi squared univariate tests and multivariable logistic regression analyses. RESULTS Of 194,073 women who underwent IR, 136,668 (70.4%) received implant-based IR and 57,405 (29.6%) received AR. Of those who underwent AR procedures, 31,336 (54.6%) received microsurgical flaps and 26,680 (46.5%) received pedicled flaps. Utilization of deep inferior epigastric perforator (DIEP) flaps increased significantly (28.6-42.5% of AR, P < 0.001). Predictors of AR were Black race [adjusted odds ratio (AOR) = 1.46, P < 0.001], lower Elixhauser Comorbidity Index (AOR = 1.25, P < 0.001), private insurance (AOR = 1.07, P = 0.030), body mass index (BMI) ≥ 30 kg/m2 (AOR = 1.38, P < 0.001), urban teaching hospital designation (AOR = 1.77, P < 0.001), and high hospital volume (AOR = 3.11, P < 0.001). Similar factors were associated with the use of microsurgical flaps. AR and microsurgical flaps were associated with higher rates of acute inpatient complications, resource utilization and length of stay (LOS) compared with implant-based IR and pedicled flaps, respectively. CONCLUSION Implant-based IR remains the most common type of IR, although rates of microsurgical AR are on the rise. Follow-up of complications, costs, and quality-of-life measures may show that AR provides long-term high-value care despite upfront morbidity, cost, and use of hospital resources.
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Affiliation(s)
- Ava D Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Carlie K Thompson
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Deanna J Attai
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Jennifer L Baker
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Ginger Slack
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Maggie L DiNome
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Minna K Lee
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, USA.
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23
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Venkatesh A, Khajuria A. Direct-to-Implant Breast Reconstruction in Patients Undergoing Post-Mastectomy Radiotherapy. Ann Surg Oncol 2020; 27:919-920. [PMID: 32705515 DOI: 10.1245/s10434-020-08907-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Ashwin Venkatesh
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Ankur Khajuria
- Kellogg College, University of Oxford, 60-62 Banbury Rd, Park Town, Oxford, OX2 6PN, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Plastic Surgery, St Thomas' Hospital, London, UK
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24
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Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare? Plast Reconstr Surg 2020; 146:494e-495e. [PMID: 32639425 DOI: 10.1097/prs.0000000000007176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Risk-reducing mastectomy: a case series of 124 procedures in Brazilian patients. Breast Cancer Res Treat 2020; 181:69-75. [PMID: 32215763 DOI: 10.1007/s10549-020-05582-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/20/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Women with mutations in breast cancer predisposition genes have a significantly higher lifetime risk of developing breast cancer and can opt for risk-reducing mastectomy. Women with positive family history of cancer can also opt for prophylactic surgery as a preventive method in selected cases. Current studies showed reduced risk of developing breast cancer after prophylactic nipple-sparing mastectomy, however, despite the good clinical outcomes, one of the main concerns regarding nipple-sparing mastectomy (NSM) is the oncological safety of nipple-areola complex preservation. In this study, we aimed to evaluate the indications, complication rates, and unfavorable events of 62 Brazilian patients that underwent risk-reducing NSM from 2004 to 2018. METHODS Patient data were reviewed retrospectively and descriptive statistics were utilized to summarize the findings. RESULTS The mean patients age was 43.8 years. The main indication for risk-reducing NSM was the presence of pathogenic mutation (53.3%), followed by atypia or lobular carcinoma in situ (25.8), and family history of breast cancer and/or ovarian cancer (20.9%). There were four (3.2%) incidental diagnosis of ductal carcinoma in situ and one invasive ductal carcinoma (0.8%). From the 124 prophylactic NSM performed, two (1.6%) complications had occurred: one (0.8%) infection and one (0.8%) partial nipple necrosis. In a mean follow-up of 50 months, there was one (1.6%) newly diagnosed breast cancer in the 62 patients undergoing prophylactic NSM. CONCLUSIONS Our findings demonstrated efficacy and safety to perform NSM as prophylactic surgery with good oncological outcomes and low complication rates in a case series of Brazilian patients.
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