1
|
Finkelstein ER, Laureano NV, Azizi A, Smartz T, Zheng C, Lessard AS, Panthaki Z, Oeltjen J, Kassira W. Prepectoral Direct-to-Implant versus Staged Tissue Expander Breast Reconstruction: A Comparison of Complications. Plast Reconstr Surg 2024; 154:224e-232e. [PMID: 37699106 DOI: 10.1097/prs.0000000000011053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane. METHODS The authors retrospectively reviewed 348 patients who underwent 536 total immediate, prepectoral implant-based breast reconstructions between January of 2018 and December of 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients who underwent DTI versus TE reconstruction up to 1 year after surgery. RESULTS Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction ( P = 0.1813), respectively. The overall infection rate was 16.4% ( n = 57). DTI patients had a significantly greater incidence of wounds ( P < 0.0001), including minor ( P < 0.0011) and major wounds ( P < 0.0053). Significantly greater mastectomy resection weights were found for DTI patients who experienced any complication ( P < 0.0076), postoperative wounds ( P < 0.0001), and major wounds specifically ( P < 0.0035). Compared with medium-thickness acellular dermal matrix (ADM), extra thick ADM was associated with significantly increased rates of infection ( P < 0.0408) and wounds ( P < 0.0001). CONCLUSIONS Prepectoral DTI reconstruction in patients with adequate flap perfusion may have complication rates comparable to staged TE reconstruction, apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infection and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights who desire comparable or smaller implant volumes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Emily R Finkelstein
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Natalia Vidal Laureano
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Armina Azizi
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Taylor Smartz
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Caiwei Zheng
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Anne-Sophie Lessard
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Zubin Panthaki
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - John Oeltjen
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| | - Wrood Kassira
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine
| |
Collapse
|
2
|
Zhao J, Chen Z, Wang M, Hai L, Xiao C. Transaxillary Single-Port Endoscopic Nipple-Sparing Mastectomy with Immediate Implant-based Breast Reconstruction in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy or Not: A Comparative Study with Analysis of Surgical Complications and Patient-Reported Outcomes. Aesthetic Plast Surg 2023; 47:2304-2321. [PMID: 37700196 DOI: 10.1007/s00266-023-03644-0] [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: 06/20/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND In most cases, transaxillary single-port endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction (E-NSM-IIBR) is conducted in patients with early-stage breast cancer, ensuring surgical safety while achieving improved breast aesthetics. However, whether E-NSM-IIBR is appropriate in patients undergoing neoadjuvant chemotherapy (NAC) is still unclear. The aim of this study was to report the surgical safety and patient-reported outcomes (PROs) of breast cancer patients who underwent E-NSM-IIBR with NAC in comparison to those who did not receive NAC. METHODS A retrospective cohort study was conducted on patients who underwent E-NSM-IIBR with or without NAC at a single center between January 2021 and July 2022. Patient demographics, postoperative complications, and PROs evaluated using the BREAST-Q version 2.0 questionnaire were compared between the two groups. Factors associated with PROs at 9 months after surgery were assessed with linear regression analysis. RESULTS A total of 92 patients who underwent E-NSM-IIBR were included in the study, with 27 patients receiving NAC and 65 patients not receiving NAC. There was no significant difference in the incidence of postoperative complications between the two groups. The BREAST-Q version 2.0 questionnaire was completed by 24 out of 27 patients (88.9%) in the NAC group and 59 out of 65 patients (90.8%) in the non-NAC group at 9 months after surgery. The patient-reported outcomes in various domains of the BREAST-Q did not show a significant difference between the two cohorts. The results of the multiple linear regression analysis indicated that in the both groups age (β = - 0.985, 95% CI - 1.598 to - 0.371, p = 0.003 in the NAC group; β = - 0.510, - 1.011 to - 0.009, p = 0.046 in the non-NAC group) and rippling (β = - 21.862, - 36.768 to - 6.955, p = 0.006 in the NAC group; β = - 7.787, - 15.151 to - 0.423, p = 0.039 in the non-NAC group) significantly impacted the patients' satisfaction with breasts, and PMRT was negatively associated with patients' physical well-being of chest (β = - 13.813, - 26.962 to - 0.664, p = 0.040 in the NAC group; β = - 18.574, - 30.661 to - 6.487, p = 0.003 in the non-NAC group). Our findings revealed that patients with larger implant volumes had higher scores in psychosocial well-being (β = 0.082, 0.001 to 0.162, p = 0.047), whereas implant displacement (β = - 14.937, - 28.175 to - 1.700, p=0.028) had a negative impact on patients' psychological well-being in the non-NAC group. However, our results did not demonstrate any significant influencing factors on patients' psychosocial well-being within the NAC group. CONCLUSION Our preliminary experiences confirm that E-NSM-IIBR is a safe option for selected patients even after NAC, with favorable patient-reported outcomes comparable with those in the primary surgery setting. The postoperative long-term outcomes of patients who undergo radiation therapy after NAC merit further investigation in the future. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
Affiliation(s)
- Jingjing Zhao
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Huan-Hu-Xi Road, He-Xi District, Tianjin, China
| | - Zujin Chen
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Huan-Hu-Xi Road, He-Xi District, Tianjin, China
| | - Mengdie Wang
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Huan-Hu-Xi Road, He-Xi District, Tianjin, China
| | - Linyue Hai
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Huan-Hu-Xi Road, He-Xi District, Tianjin, China
| | - Chunhua Xiao
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Huan-Hu-Xi Road, He-Xi District, Tianjin, China.
| |
Collapse
|
3
|
Scarabosio A, Contessi Negrini F, Pisano G, Beorchia Y, Castriotta L, De Francesco F, Riccio M, Parodi PC, Zingaretti N. Prepectoral Direct-To-Implant One-Stage Reconstruction With ADMs: Safety and Outcome in "Thin Patients". Clin Breast Cancer 2023; 23:e507-e514. [PMID: 37735018 DOI: 10.1016/j.clbc.2023.08.007] [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: 07/26/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Prepectoral direct-to-implant reconstruction with acellular dermal matrix (ADM) represents a safe, fast, and successful option in breast reconstruction in a selected cohort of patients. Nowadays, this procedure is considered challenging in thin. Meanwhile, his cohort has not been accurately analyzed yet. METHODS A single institution retrospective cohort study was performed between January 2019 and March 2023 in all women who underwent mastectomy. Biometrical and clinical data were recorded. Also, surgical technique, operating room (OR) time, mastectomy weights, implant choice, and acellular dermal matrix (ADM) types were properly noted. Postoperative complications represented the main topic: these were classified into early and late ones based on onset time. At least 12-month follow-up was required. A comparison between thin and ideal body mass index (BMI) populations was performed. RESULTS Early complications did not seem to differ between the 2 groups with 37.8% and 38.9% of women having at least 1 early complication in thin and ideal-weight women, respectively (P = .919). In univariable regression analysis, compared with women with a BMI of 22.1 to 25.0, women with a BMI ≤ 22.0 were associated with an increased risk of late complications of 2.84 (1.13-7.14). Specifically, thin women appeared to have a 3-fold increased risk (OR = 2.97, 95% CI 1.08-8.18) of ripples/wrinkles compared with women with ideal weight. CONCLUSIONS Prepectoral reconstruction with ADM in thin patients may be considered as safe as in standard BMI patients. Rippling may be more frequent, but, whenever needed, easy to correct with a few sessions of lipo-grafts. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Anna Scarabosio
- Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Filippo Contessi Negrini
- Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Gaetano Pisano
- Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Yvonne Beorchia
- Institute of Hygiene and Evaluative Epidemiology, Friuli Centrale University Health Authority, Udine, Italy
| | - Luigi Castriotta
- Institute of Hygiene and Evaluative Epidemiology, Friuli Centrale University Health Authority, Udine, Italy
| | - Francesco De Francesco
- Department of Reconstructive Surgery and Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy; Accademia del Lipofilling, Research and Training Center in Regenerative Surgery, Jesi, Italy
| | - Michele Riccio
- Department of Reconstructive Surgery and Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy; Accademia del Lipofilling, Research and Training Center in Regenerative Surgery, Jesi, Italy
| | - Pier Camillo Parodi
- Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medical Area (DAME), University of Udine, Udine, Italy; Accademia del Lipofilling, Research and Training Center in Regenerative Surgery, Jesi, Italy.
| | - Nicola Zingaretti
- Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medical Area (DAME), University of Udine, Udine, Italy; Accademia del Lipofilling, Research and Training Center in Regenerative Surgery, Jesi, Italy
| |
Collapse
|
4
|
Asaad M, Hassan AM, Morris N, Kumar S, Liu J, Butler CE, Selber JC. Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction. Aesthet Surg J 2023; 43:NP774-NP786. [PMID: 37265099 DOI: 10.1093/asj/sjad175] [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: 04/12/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established. OBJECTIVES The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane. METHODS We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation. RESULTS The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction. CONCLUSIONS Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes. LEVEL OF EVIDENCE: 4
Collapse
|
5
|
Bigarella LG, Ballardin AC, Couto LS, de Ávila ACP, Ballotin VR, Ingracio AR, Martini MP. The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis. Aesthet Surg J 2022; 42:795-807. [PMID: 35037936 DOI: 10.1093/asj/sjab397] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory. OBJECTIVES The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures. METHODS We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes. RESULTS Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction. CONCLUSIONS Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.
Collapse
Affiliation(s)
| | | | - Luísa Serafini Couto
- School of Medicine, Universidade de Caxias do Sul (UCS) , Caxias do Sul , Brazil
| | | | | | | | | |
Collapse
|
6
|
Prepectoral Breast Reconstruction in Morbidly Obese Patients. Plast Reconstr Surg Glob Open 2022; 10:e4261. [PMID: 35433156 PMCID: PMC9007186 DOI: 10.1097/gox.0000000000004261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/15/2022] [Indexed: 11/26/2022]
Abstract
Prosthetic breast reconstruction via the subpectoral approach in morbidly obese patients (body mass index: ≥40 kg/m2) has been reported to be associated with an increased risk of perioperative complications and poor outcomes. Further, immediate reconstruction appears to carry a higher risk of poor outcomes than delayed reconstruction in this population. The impact of morbid obesity on outcomes after prepectoral breast reconstruction has not yet been evaluated, and such was the purpose of this study.
Collapse
|
7
|
Ching AH, Lim K, Sze PW, Ooi A. Quality of life, pain of prepectoral and subpectoral implant-based breast reconstruction with a discussion on cost: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2550-2560. [PMID: 35393263 DOI: 10.1016/j.bjps.2022.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/12/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Prepectoral implant-based breast reconstruction (PIBR) has regained popularity, despite decades-long preference for subpectoral implant placement. This paper aims to compare patient-reported outcomes (PRO) between prepectoral and subpectoral approaches to implant-based breast reconstruction (IBBR). The primary PRO was with the BREAST-Q, and postoperative pain scores, while the secondary outcomes were complication rates. METHODS A comprehensive literature search of the PubMed library was performed. All studies on patients undergoing IBBR after mastectomy that compared prepectoral to subpectoral placement and PROM or postoperative pain were included. RESULTS A total of 3789 unique studies of which 7 publications with 216 and 332 patients who received prepectoral and subpectoral implants, respectively, were included for meta-analysis. Patients with prepectoral implant placement had significantly higher satisfaction with the outcome (p = 0.03) and psychosocial well-being (p = 0.03) module scores. The pain was lower in patients with prepectoral implants on postoperative day 1 (p<0.01) and day 7 (p<0.01). The subgroup analysis of prepectoral breast implants showed that complete acellular dermal matrix coverage had lower rates of wound dehiscence (p<0.0001), but there were no significant differences in complications between one-stage and two-stage procedures. CONCLUSION Overall, patients with prepectoral implants reported higher BREAST-Q scores and lower postoperative pain and lower complications rates than patients with subpectoral implants. In appropriately selected patients, prepectoral implant placement with ADM coverage, be it the primary placement of an implant or placement of a tissue expander before definitive implant placement, should be the modality of choice in patients who choose IBBR. Further research should focus on patient selection, strategies to reduce cost and cost-benefit analysis of PIBR.
Collapse
Affiliation(s)
- Ann Hui Ching
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kimberley Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pek Wan Sze
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
| | - Adrian Ooi
- Polaris Plastic & Reconstructive surgery, Singapore.
| |
Collapse
|
8
|
Leitner HS, Pauzenberger R, Ederer IA, Radtke C, Hacker S. BMI Specific Complications Following Implant-Based Breast Reconstruction after Mastectomy. J Clin Med 2021; 10:jcm10235665. [PMID: 34884366 PMCID: PMC8658513 DOI: 10.3390/jcm10235665] [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: 11/04/2021] [Revised: 11/27/2021] [Accepted: 11/28/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Breast reconstruction has a positive impact on body image and quality of life for women after experiencing the physically and psychologically demanding process of mastectomy. Previous studies have presented body mass index (BMI) as a predictor for postoperative complications after breast reconstruction, however, study results vary. This retrospective study aimed to investigate the impact of patients’ BMI on postoperative complications following implant-based breast reconstruction. Methods: All implant-based breast reconstructions performed at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Vienna from January 2001 to March 2018 were evaluated. A total of 196 reconstructed breasts among 134 patients met eligibility criteria. Demographic data, surgical techniques, as well as major and minor complications within a one-year follow-up period were analyzed. Results: Patients’ BMI did not show a significant impact on complication rates. The overall incidence of postoperative complications was 30.5% (40/131) of which 17.6% required reoperation. Impaired wound healing (18.3%), seroma (6.1%), hematoma (4.6%), capsular contraction (4.6%) and infection (3.8%) were the most common complications. Conclusion: In our study cohort, BMI was not associated with a significantly higher risk of complications. However, postoperative complications significantly increased with a longer operative time and resulted in an extended length of hospital stay.
Collapse
Affiliation(s)
- Helena Sophie Leitner
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.S.L.); (R.P.); (C.R.)
| | - Reinhard Pauzenberger
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.S.L.); (R.P.); (C.R.)
- Privatordination Dr. Pauzenberger, 4861 Schörfling am Attersee, Austria
| | - Ines Ana Ederer
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, 60431 Frankfurt, Germany;
| | - Christine Radtke
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.S.L.); (R.P.); (C.R.)
| | - Stefan Hacker
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.S.L.); (R.P.); (C.R.)
- Department of Plastic, Aesthetic and Reconstructive Surgery, State Hospital Wiener Neustadt, 2700 Wiener Neustadt, Austria
- Correspondence: ; Tel.: +43-2622-9004-23401
| |
Collapse
|
9
|
Gender-Affirming Mastectomy in Transmasculine Patients: Does Obesity Increase Complications or Revisions? Ann Plast Surg 2021; 87:24-30. [PMID: 33559996 DOI: 10.1097/sap.0000000000002712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity can often be a barrier to gender-affirming top surgery in transmasculine patients because of concern for increased surgical site complications. STUDY DESIGN All adult patients (N = 948) within an integrated health care system who underwent gender-affirming mastectomy from 2013 to 2018 were retrospectively reviewed to evaluate the relationship between obesity and surgical site complications or revisions. RESULTS One third of patients (n = 295) had obese body mass index (BMI), and those patients were further stratified into obesity class I (BMI of 30-34.9 kg/m2, 9.4%), class II (BMI of 35-39.9 kg/m2, 8.9%), and class III (BMI of ≥40 kg/m2, 2.9%). A majority of patients across BMI categories underwent double incision surgery. There were no significant differences in complications or revisions between patients with obesity versus those with normal BMI, when BMI was treated as a categorical or continuous variable and when evaluating only patients who underwent double incision surgery. CONCLUSIONS Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use. Further research is needed to understand risks associated with the highest BMI (≥40 kg/m2) patients and to assess patient satisfaction with surgical outcome.
Collapse
|
10
|
Khan A, Tasoulis MK, Teoh V, Tanska A, Edmonds R, Gui G. Pre-pectoral one-stage breast reconstruction with anterior biological acellular dermal matrix coverage. Gland Surg 2021; 10:1002-1009. [PMID: 33842244 DOI: 10.21037/gs-20-652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Pre-pectoral implant breast reconstruction (IBR) is gaining popularity. Several techniques using different types of meshes and methods of placement have been described, but no method is currently considered standard. The aim of this study was to evaluate the outcomes of pre-pectoral IBR using acellular dermal matrix (ADM) for anterior implant cover. Methods Retrospective cohort study of consecutive patients who underwent pre-pectoral IBR between November 2016 to August 2018. Data on demographics, adjuvant therapies and operative technique was collected. Postoperative complications, length of hospital stay and secondary cosmetic procedures were recorded. Statistical analysis was performed using descriptive statistics, non-parametric tests and logistic regression. Results One hundred and eleven pre-pectoral IBR were performed in 65 patients. Median age was 41 [interquartile range (IQR), 35-51.5] years, and BMI 22 (IQR, 20.4-24.4) kg/m2. Therapeutic mastectomy was performed in 33 procedures with nipples preservation in 78 cases. The median mastectomy weight and implant volume was 360 (IQR, 220-533) gr, and 445 (IQR, 400-475) cc respectively. At a median follow-up of 18 (IQR, 12-22.5) months, 37 mastectomies had at least 1 complication, but only 12 required surgery. The implant loss rate was 4.5% (5 cases). Lipofilling as secondary procedure was performed in 10.8% of cases. Factors associated with post-operative complications on univariate analysis were nipple preservation (P=0.028), BMI (P=0.01) and implant volume (P=0.027) but these did not remain significant on multivariate analysis. Conclusions Pre-pectoral IBR using ADM for anterior implant cover is associated with low complication and reconstructive failure rate. Patient selection and meticulous surgical technique are important for successful outcome.
Collapse
Affiliation(s)
- Ayesha Khan
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Victoria Teoh
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aleksandra Tanska
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ruth Edmonds
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gerald Gui
- Breast Surgery Unit, The Royal Marsden NHS Foundation Trust, London, UK
| |
Collapse
|
11
|
Heidekrueger PI, Fritschen U, Moellhoff N, Germann G, Giunta RE, Zeman F, Prantl L. Impact of body mass index on free DIEP flap breast reconstruction: A multicenter cohort study. J Plast Reconstr Aesthet Surg 2021; 74:1718-1724. [PMID: 33461890 DOI: 10.1016/j.bjps.2020.12.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/26/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. This study analyzed the largest series of microsurgical breast reconstructions in Germany using deep inferior epigastric perforator (DIEP) flaps, with a focus on the impact of patient body mass index (BMI). PATIENTS AND METHODS A total of 3911 female patients underwent 4561 free DIEP flap breast reconstructions across 22 different centers. The cases were divided into five groups using World Health Organization BMI criteria: underweight group (BMI <18.5 kg/m2), normal weight/ control group (BMI: 18.5-24.9 kg/m2), overweight group (BMI: 25-29.9 kg/m2), moderately obese group (BMI: 30-34.9 kg/m2), and severely obese group (BMI ≥ 35 kg/m2). Surgical complications were accounted for and the five BMI groups were then compared. RESULTS Overall, there was no significant difference regarding the rate of partial- and total flap loss between all BMI groups (p > 0.05). However, overweight and obese patients showed significantly higher rates of postoperative infections at the donor and recipient sites than the control group (donor site infections: overweight 0.6%; moderately obese 0.9%; severely obese 2.4% vs control 0.1%; all p<0.01; recipient site infections: overweight 0.5%; moderately obese 0.8%; severely obese 1.4% vs control 0.1%; all p < 0.05). The rate of medical complications also differed significantly between groups, with the highest rates in moderately and severely obese women (moderately obese: 8.4%; severely obese: 13.0% vs. control: 5.1%; p < 0.01). CONCLUSION Our findings suggest that successful free tissue transfer can be achieved even in an underweight and severely obese population with acceptable risk for complications.
Collapse
Affiliation(s)
- P I Heidekrueger
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany.
| | - Uv Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, Berlin, Germany
| | - N Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich Germany
| | - G Germann
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany; Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany; Department of Plastic, Reconstructive, Aesthetic and Handsurgery, ETHIANUM Klinik Heidelberg, Vossstrasse 6, 69115 Heidelberg, Germany
| | - R E Giunta
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich Germany
| | - F Zeman
- Centre for Clinical Studies, University Medical Centre Regensburg, Regensburg, Germany
| | - L Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| |
Collapse
|
12
|
Roubaud MS, Carey JN, Vartanian E, Patel KM. Breast reconstruction in the high-risk population: current review of the literature and practice guidelines. Gland Surg 2021; 10:479-486. [PMID: 33634005 DOI: 10.21037/gs-2020-nfbr-09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Breast reconstruction is an important part of the cancer treatment paradigm and the psychosocial benefits are well described in the literature. Notably, breast reconstruction restores both the functional and emotional losses patients experience due to tumor resection. Post-cancer quality of life is an important benchmark of successful treatment; therefore, breast reconstruction is an essential component that should be offered whenever possible. Over time, reconstructive techniques and outcomes have improved dramatically resulting in better patient safety and decreased operative morbidity. When counseling a patient for surgery, the provider must consider all aspects of a patient's health. Ideally, breast cancer patients should be physically, emotionally, and oncologically appropriate candidates for reconstruction. However, in concerted effort to provide opportunities for as many patients as possible, the definition of who is a good candidate for reconstruction has evolved to include higher risk patients. These patients include those with advanced age, nicotine use, obesity, and significant ptosis. With improvements in surgical procedures and perioperative care, this population may also benefit from restorative surgery. However, the exact risk of complications and necessary counseling has gone largely undefined in this population. This article examines particular "high-risk" groups that may be challenging for extirpative and reconstructive surgeons and offers current guidelines for practice.
Collapse
Affiliation(s)
- Margaret S Roubaud
- Department of Plastic and Reconstructive Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph N Carey
- Department of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA, USA
| | - Emma Vartanian
- Department of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ketan M Patel
- Department of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
13
|
Salibian AA, Frey JD, Choi M, Karp NS. Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes. Aesthet Surg J 2020; 40:S1-S12. [PMID: 33202011 DOI: 10.1093/asj/sjaa130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.
Collapse
Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Nolan S Karp
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| |
Collapse
|
14
|
Dual-Plane versus Prepectoral Breast Reconstruction in High–Body Mass Index Patients. Plast Reconstr Surg 2020; 145:1357-1365. [DOI: 10.1097/prs.0000000000006840] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Gabriel A, Sigalove S, Pfaffenberger M, Eldenburg E, Gold R, O'Rorke E, Maxwell GP. Povidone-iodine Does Not Affect Acellular Dermal Matrix Integration in Patients Undergoing 2-staged, Prepectoral, Breast Reconstructive Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2758. [PMID: 32440426 PMCID: PMC7209843 DOI: 10.1097/gox.0000000000002758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 02/11/2020] [Indexed: 11/25/2022]
Abstract
Background: Povidone-iodine has been traditionally used as an antimicrobial agent to irrigate the breast pocket and rinse the prosthesis before placement in the pocket. Use of povidone-iodine with breast implants was banned from 2000 to 2017. During this period, acellular dermal matrix (ADM) was introduced to breast surgery. In nonclinical studies, povidone-iodine can impair collagen synthesis and kill fibroblasts. Cellular repopulation was critical for ADM integration. Whether povidone-iodine impacts ADM integration was unknown. Methods: Patients who underwent immediate, prepectoral, 2-staged breast reconstruction were included in this retrospective study. Study population was divided into povidone-iodine–treated patients and triple-antibiotic–treated patients. The breast pockets were rinsed with the antimicrobial agent, and the prostheses and ADMs were presoaked in the agent perioperatively. At implant exchange, the extent of ADM integration was clinically assessed. ADM integration was defined as >25% of matrix vascularization. ADM integration and postoperative complications were compared between the groups. Results: A total of 111 patients (257 reconstructions) were included—58 patients (111 reconstructions) were exposed to povidone-iodine and 53 patients (97 reconstructions) to triple-antibiotic solution. ADM integration was noted in 97% of breasts in each group. Integrated matrices appeared healthy, had no signs of foreign body reaction, and demonstrated punctate bleeding. Complications did not differ between the groups, including the rate of infections, seroma, and expander loss. Conclusion: Irrigation of the breast pocket and presoaking of the prosthesis and ADM with povidone-iodine appear to have no adverse consequences on clinical outcomes and did not impede matrix integration.
Collapse
Affiliation(s)
- Allen Gabriel
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, Calif
| | - Steven Sigalove
- Private Practice, Scottsdale Plastic Surgery, Scottsdale, Ariz
| | | | | | - Rebecca Gold
- Elson S. Floyd College of Medicine Washington State University, Vancouver, Wash
| | - Erin O'Rorke
- Elson S. Floyd College of Medicine Washington State University, Vancouver, Wash
| | - G Patrick Maxwell
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, Calif
| |
Collapse
|
16
|
Body Mass Index Can Predict Outcomes in Direct-to-Implant Prepectoral Breast Reconstruction. Plast Reconstr Surg 2020; 145:867e-868e. [DOI: 10.1097/prs.0000000000006703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
17
|
Bloom JA, Patel K, Cohen S, Chatterjee A, Homsy C. Prepectoral Breast Reconstruction: An Overview of the History, Technique, and Reported Complications . OPEN ACCESS SURGERY 2020. [DOI: 10.2147/oas.s201298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|