Managing the Opposite Breast: Contralateral Symmetry Procedures

Immediate Symmetrization of the Contralateral Breast in Breast Reconstruction-Revision, Complications, and Satisfaction: A Systematic Review

Background

It is desirable to achieve breast symmetry after unilateral surgery for breast tumors. Thus, contralateral balancing is often required, but it is still debated whether symmetrization surgery should be performed alongside reconstruction or as a delayed procedure. Therefore, we aimed to compare revision rates, complication rates, and satisfaction levels between those who underwent immediate versus delayed symmetrization.

Methods

A systematic review was designed to summarize the revision surgery rates, complication rates, and satisfaction levels of patients who underwent contralateral breast symmetrization at the same time as breast reconstruction. We included articles published between 2010 and 2022 in databases such as PubMed, MEDLINE, and Embase.

Results

Most studies showed no difference or lower revision rates for immediate symmetrization, except for one study where immediate symmetrization had a revision rate twice that of delayed symmetrization. There were no significant differences in complication rates between the two groups. Regarding satisfaction levels, most studies showed that the immediate group had higher scores regardless of statistical significance; however, breast-related satisfaction was significantly higher in the immediate group than in the delayed group.

Conclusion

This systematic review demonstrates that immediate symmetrization surgery does not increase revision surgery and complication rates or decrease satisfaction levels.

Analysis of Breast Aesthetic Revision Procedures after Unilateral Abdominal-based Free-flap Breast Reconstruction: A Single-center Experience with 1251 Patients

Although autologous free-flap breast reconstruction is the most durable means of reconstruction, it is unclear how many additional operations are needed to optimize the aesthetic outcome of the reconstructed breast. The present study aimed to determine the average number of elective breast revision procedures performed for aesthetic reasons in patients undergoing unilateral autologous breast reconstruction and to analyze variables associated with undergoing additional procedures.

Methods

A retrospective review of all unilateral abdominal-based free-flap breast reconstructions performed from 2000 to 2014 was undertaken at a tertiary academic center.

Results

Overall, 1251 patients were included in the analysis. The average number of breast revision procedures was 1.1 ± 0.9, and 903 patients (72.2%) underwent at least one revision procedure. Multiple logistic regression analysis demonstrated that younger age, higher body mass index, and prior oncologic surgery on the reconstructed breast were factors associated with increased likelihood of undergoing a revision procedure. The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m²) increase in a patient's body mass index. Multiple Poisson regression modeling demonstrated that younger age, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were significant factors associated with undergoing a greater number of revision procedures.

Conclusions

Most patients who undergo unilateral autologous breast reconstruction require at least one additional operation to optimize their breast aesthetic results. Young age and obesity increase the likelihood of undergoing additional operations. These findings can aid reconstructive microsurgeons in counseling patients and establishing patient expectations prior to their undergoing microvascular breast reconstruction.

Comparison of breast volume change between oncoplastic breast-conserving surgery with radiation therapy and a simultaneous contralateral balancing procedure through the inverted-T scar technique

Background

Reduction mammoplasty or mastopexy is performed as an additional balancing procedure in patients with large or ptotic breasts who undergo breast-conserving surgery (BCS). Radiation therapy on breasts that have undergone surgery may result in changes in the volume. This study presents a comparative analysis of patients who received post-BCS balancing procedures to determine whether volume changes were larger in breasts that received radiation therapy than on the contralateral side.

Methods

Thirty-six participants were selected among patients who received BCS using the inverted-T scar technique between September 2012 and July 2017, were followed up for 2 or more years, and had pre-radiation therapy computed tomography images and post-radiation therapy images taken between 12 and 18 months after completion. The average age of the participants was 53.5 years, their average body mass index was 26.62 kg/m².

Results

The pre- and post-radiation therapy volumes of the breasts receiving BCS were 666.08±147.48 mL and 649.33±130.35 mL, respectively. In the contralateral breasts, the volume before radiation therapy was 637.69±145.72 mL, which decreased to 628.14±166.41 mL after therapy. The volume ratio of the affected to the contralateral breasts was 1.05±0.10 before radiation therapy and 1.06±0.12 after radiation therapy.

Conclusions

The ratio of the volume between the two breasts immediately after surgery and at roughly 18 months postoperatively was not significantly different (P=0.98). For these reasons, we recommend a simultaneous single-stage balancing procedure as a reasonable option for patients who require radiation therapy after BCS without concerns regarding volume change.

Update in Direct-to-Implant Breast Reconstruction

Implant-based reconstruction (IBR) remains the most commonly utilized breast reconstruction option for post-mastectomy patients. IBR can be approached as either a one-stage reconstruction or a two-stage reconstruction. Facilitated by improvements in surgical technology and advanced techniques, one-stage reconstruction, also known as direct-to-implant (DTI) reconstruction, involves the insertion of an implant at the time of mastectomy. The decision to pursue either a DTI or a two-stage reconstruction is based on several factors, including the patient's overall health, expected risk of postoperative complications, and associated costs to both the patient and hospital.

Striving to Do No Harm and Yet Respect Patient Autonomy: Plastic Surgeons' Perspectives of the Consultation for Breast Reconstruction with Women Who Have Early-Stage Breast Cancer

BACKGROUND

Rates of contralateral prophylactic mastectomy (CPM) have doubled over the last decade among women considered low risk for developing contralateral breast cancer. Despite the strong association between CPM and breast reconstruction, little is known about the clinical encounter between patients and plastic surgeons. A qualitative study was performed to understand how plastic surgeons describe their roles in the treatment decision-making process through their consultations with women who have unilateral early-stage breast cancer.

METHODS

Semi-structured interviews with Ontario plastic surgeons were conducted. An inductive and interpretive thematic approach was initially used to analyze the data. The four principles of biomedical ethics then served as the conceptual lens to interpret the findings.

RESULTS

The participants in this study were 18 plastic surgeons, and data saturation was reached. Four themes were identified: maintaining non-maleficence, supporting patient autonomy, delivering (un)equal health care, and providing care to enhance well-being. The ongoing push-pull between competing ethical principles was the overarching theme, specifically, striving to balance parallel responsibilities to do no harm while also respecting patients' rights to make their own healthcare decisions.

CONCLUSIONS

In this patient-centric climate, it is important to acknowledge that patients may value outcomes such as achieving greater peace of mind above other clinical factors and are willing to incur additional risks to achieve these goals. Shared decision-making will help to reveal the rationale underlying each individual's treatment choice, which in turn will allow physicians to appropriately weigh patient requests with the best available medical evidence when counseling women on decision-making for breast cancer care.

Impact of Contralateral Symmetry Procedures on Long-Term Patient-Reported Outcomes following Unilateral Prosthetic Breast Reconstruction

BACKGROUND

 One aim of unilateral postmastectomy breast reconstruction (BR) is to restore symmetry with the contralateral breast. As such, unilateral prosthetic reconstruction often requires a contralateral symmetry procedure (CSP). There is sparse literature on the impact of CSPs on long-term patient-reported outcomes (PROs) such as satisfaction and health-related quality of life (HRQoL). This study aims to describe PROs following CSPs, using a validated PRO tool, BREAST-Q. The hypothesis is that CSPs are associated with greater patient-reported satisfaction and HRQoL.

METHODS

 This study is a single institutional analysis of prospectively collected BREAST-Q scores of patients who underwent unilateral prosthetic BR during 2011 to 2015. Women 18 years and older with BREAST-Q scores measured ≥ 9months after BR with or without CSP(s) at the time of expander replacement were included. Patients were classified into four subcohorts: augmentation, mastopexy, reduction, and no symmetry procedure (controls). Sociodemographic, clinical characteristics, and BREAST-Q scores were analyzed. Multivariable linear regression was performed.

RESULTS

 Of 553 patients, 67 (12%) underwent contralateral augmentation, 68 (12%) mastopexy, 93(17%) reduction, and 325 (59%) were controls. Mean follow-up time was 52 months. Satisfaction with breast and outcomes were higher in the augmentation compared with the control groups (p = 0.01). On multivariable analysis, augmentation remained an independent predictor of satisfaction with breast (p = 0.04). Physical well-being scores were lower for contralateral mastopexy and reduction compared with the controls with a trend toward statistical significance on multivariable models. Psychological and sexual well-being was similar across groups.

CONCLUSION

 Prosthetic reconstruction with contralateral breast augmentation was associated with greater satisfaction with breast and reconstructive outcome. In contrast, breast reduction and mastopexy procedures demonstrated equivalent satisfaction with breasts compared with controls but may be associated with lower physical well-being. Such information can be used to improve the shared decision-making process for women who choose unilateral prosthetic BR.

Selection of Implants in Unilateral Prosthetic Breast Reconstruction and Contralateral Augmentation

BACKGROUND

In breast reconstruction using implants after unilateral mastectomy, it is challenging to create a natural, ptotic contour, and asymmetry is a potential drawback. To achieve breast symmetry and an ideal shape for both breasts, we performed contralateral augmentation in patients undergoing breast reconstruction with implants.

METHODS

Patients underwent unilateral mastectomy and 2-stage reconstruction. During the second stage of the procedure, contralateral augmentation mammoplasty was performed. Preoperatively, we obtained the patients' demographic information, and we then assessed breast volume, the volume and dimensions of the inserted implants, and complications. Breast symmetry was observed by the surgeon and was assessed by measuring the disparity between the final volume of each breast.

RESULTS

Contralateral augmentation was performed in 52 cases. When compared to patients who did not undergo a contralateral balancing procedure, patients who received contralateral augmentation were younger, thinner, and had smaller breasts. During implant selection for contralateral augmentation, we chose implants that were approximately 1 cm shorter in width, 1 level lower in height, and 1 or 2 levels lower in projection than the implants used for reconstruction. The postoperative breast contours were symmetric and the final volume discrepancy between each breast, which was measured by 3-dimensional scanning, was acceptable.

CONCLUSIONS

We demonstrate that contralateral augmentation can be recommended for patients who perceive their breasts to be small and not beautiful in order to achieve an ideal and beautiful shape for both breasts. Furthermore, this study offers guidelines for selecting the implant that will lead to the optimal aesthetic outcome.

Matching Procedures at the Time of Immediate Breast Reconstruction: An American College of Surgeons National Surgical Quality Improvement Program Study of 24,191 Patients

BACKGROUND

The purpose of this study was to assess for compounded risk of postoperative morbidity with the addition of a simultaneous contralateral breast matching procedure at the time of mastectomy and immediate breast reconstruction.

METHODS

2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program databases were used to identify cases of mastectomy and immediate breast reconstruction with and without simultaneous contralateral breast matching procedures. Matching procedures included mastopexy, reduction mammaplasty, and augmentation mammaplasty. Thirty-day postoperative morbidity was assessed using univariable and multivariable logistic regression.

RESULTS

Of 59,766 mastectomy patients, 24,191 (40 percent) underwent immediate breast reconstruction: 903 (3.7 percent) underwent matching procedures and 23,288 (96.3 percent) did not. Univariable logistic regression demonstrated that the matching procedure group had statistically significantly higher overall morbidity (OR, 1.288; 95 percent CI, 1.022 to 1.623; p = 0.032). Although surgical and systemic morbidity did not differ significantly, the matching procedure group demonstrated higher risk for superficial surgical-site infection (OR, 1.57; 95 percent CI, 1.066 to 2.31; p = 0.022), reconstruction failure (OR, 1.69; 95 percent CI, 1.014 to 2.814; p = 0.044), and pulmonary embolism (OR, 2.54; 95 percent CI, 1.01 to 6.37; p = 0.048). Controlling for possible confounders, multivariable logistic regression rendered the relationship between matching procedure and complications insignificant (OR, 1.17; 95 percent CI, 0.92 to 1.48; p = 0.2).

CONCLUSION

These data suggest that preoperative comorbidities and other patient-related factors may have a larger influence on postoperative morbidity than the addition of a contralateral matching procedure alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Benefit of simultaneous contralateral breast symmetry procedure with unilateral breast reconstruction using DIEP flaps. About 33 cases]

BACKGROUND

After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with DIEP flap.

METHODS

We evaluated 33 consecutive patients (mean age, 52.1 years) who underwent DIEP flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed and 2 patients with delayed controlateral symmetry procedures. A single-stage breast cancer reconstruction is successful if after the original reconstruction no correction for revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction.

RESULTS

In 24 patients (73%), breast reconstruction was completed after a single stage with one general anesthetic, and in 8 patients (24%), revisions were performed with two general anesthetic (7 patients) and three general anesthetic in one case. Reconstructions requiring more than one general anesthetic were due to 4 of 39 (10%) postoperative complications. Mean operating time was 485 minutes.

CONCLUSIONS

For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.

Achieving ideal breast aesthetics with autologous reconstruction

Achieving ideal breast aesthetic has become a top priority for women considering breast reconstruction following mastectomy. The use of autologous tissue is generally regarded as providing the most natural results because donor tissues quality and consistency is similar to that of the native breast. There are several donor sites that are particularly useful for autologous reconstruction that include the abdomen, gluteal region, posterior thorax, and the thigh. Traditional and microsurgical techniques can be used. Shaping is a critical component and involves a basic understanding of the footprint, conus, and skin envelope. This manuscript will review many aspects of breast shaping in-order to achieve aesthetically pleasing results in a predictable manner.

Factors to Consider in Breast Reconstruction

Women considering breast ablative therapy are confronted with a variety of decisions that include the type of mastectomy (partial, total, skin sparing, nipple areolar sparing), the type of reconstruction (prosthetic, autologous, oncoplastic) and the need for adjuvant therapy (chemotherapy, radiation). The parameters for each are multifactorial and require significant thought and counseling. Therapeutic options are essentially individualized and dependent upon a variety of factors such as tumor size and location, lymph node involvement, comorbidities, expectations and body characteristics. The role of reconstructive surgery is now well appreciated and an integral component of the multidisciplinary care of the patient and is influenced by the opinions and recommendations of surgical, medical and radiation oncologists. This manuscript will review the role of reconstructive surgery and the many factors to consider.

The efficacy of simultaneous breast reconstruction and contralateral balancing procedures in reducing the need for second stage operations

Background

Patients having unilateral breast reconstruction often require a second stage procedure on the contralateral breast to improve symmetry. In order to provide immediate symmetry and minimize the frequency and extent of secondary procedures, we began performing simultaneous contralateral balancing operations at the time of initial reconstruction. This study examines the indications, safety, and efficacy of this approach.

Methods

One-hundred and two consecutive breast reconstructions with simultaneous contralateral balancing procedures were identified. Data included patient age, body mass index (BMI), type of reconstruction and balancing procedure, specimen weight, transfusion requirement, complications and additional surgery under anesthesia. Unpaired t-tests were used to compare BMI, specimen weight and need for non-autologous transfusion.

Results

Average patient age was 48 years. The majority had autologous tissue-only reconstructions (94%) and the rest prosthesis-based reconstructions (6%). Balancing procedures included reduction mammoplasty (50%), mastopexy (49%), and augmentation mammoplasty (1%). Average BMI was 27 and average reduction specimen was 340 grams. Non-autologous blood transfusion rate was 9%. There was no relationship between BMI or reduction specimen weight and need for transfusion. We performed secondary surgery in 24% of the autologous group and 100% of the prosthesis group. Revision rate for symmetry was 13% in the autologous group and 17% in the prosthesis group.

Conclusions

Performing balancing at the time of breast reconstruction is safe and most effective in autologous reconstructions, where 87% did not require a second operation for symmetry.

Immediate Single-Stage Reconstruction of the Breast Utilizing FlexHD and Implant following Skin-Sparing Mastectomy

Introduction:

Primary reconstruction of the breast is the standard of care for patients undergoing a mastectomy for breast cancer. Surgical techniques involving immediate implant reconstruction following skin-sparing mastectomy can offer improved patient self-image and enhanced aesthetic outcomes compared with other techniques. The use of an acellular dermal matrix (ADM) as a supporting material has been shown to further improve cosmetic results. Here, we describe a technique that allows for primary reconstruction of the breast mound with implant after a skin-sparing mastectomy in a single procedure using a new form of ADM known as FlexHD.

Materials and Methods:

A total of 50 patients (85 breast reconstructions) over a period of 20 months underwent immediate reconstruction with this method using a silicone gel mammary implant. The surgical approach and complications for each patient were documented. In some patients, biopsies were obtained 2 and 6 months after initial placement of FlexHD (at the time of expander replacement) for pathologic and histologic evaluations.

Results:

All reconstructions were completed in a single-stage procedure. The technique resulted in positive aesthetic outcomes and patient satisfaction with few complications and low postoperative pain. Infections were more frequently observed following bilateral mastectomy and in patients who had previous radiation therapy or were smokers. Fibroblast migration and neovascularization of the ADM were observed at 2 months with full incorporation into native tissue at 6 months.

Conclusions:

Our experience suggests that single-stage breast reconstruction with FlexHD is a preferred approach to the primary reconstruction of the breast after mastectomy.

Challenges and economics of private breast cancer surgery practice

The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.