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Liu FC, Najafali D, Nguyen D, Momeni A. Less Is More: The Role of Mesh in Microsurgical Breast Reconstruction with Abdominal Flaps. J Reconstr Microsurg 2024. [PMID: 39168135 DOI: 10.1055/s-0044-1788929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND The use of mesh to reinforce the abdominal wall after abdominal flap harvest has been reported to decrease the risk of bulging and herniation. However, the impact of the plane of mesh placement in relation to the anterior rectus sheath (vs. no mesh) on postoperative abdominal complications remains unclear. METHODS We retrospectively analyzed the length of stay and clinical outcomes in 158 female patients who underwent breast reconstruction with 250 free abdominal flaps. Group 1 consisted of patients who underwent polypropylene sublay-onlay ("sandwich") mesh placement (N = 70) versus polypropylene sublay-only mesh (group 2; N = 54) versus primary fascial repair without mesh (group 3; N = 34). RESULTS Patient demographics and comorbidities were comparable between study groups, except for rates of neoadjuvant chemotherapy (group 1: 53% vs. group 2: 33% vs. group 3: 24% [p < 0.01]), postoperative follow-up in months (group 1: 21.5; group 2: 11.5; group 3: 7.6 [p < 0.01]), and length of stay in days (group 1: 4.9 vs. group 2: 4.4 vs. group 3: 3.3 [p < 0.01]). No differences were observed in breast flap and donor-site complications between study groups. Patients in group 3 required significantly lower oral morphine equivalent units postoperatively compared with those in groups 1 and 2 (group 1:185.5 vs. group 2: 79.7 vs. group 3: 71.6 [p < 0.01]). CONCLUSION Abdominal donor-site closure without mesh was associated with a shorter length of stay and less narcotic intake without an increase in donor-site complications. These findings should be considered when deciding to place mesh for donor-site closure after abdominal flap harvest.
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Affiliation(s)
- Farrah C Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Daniel Najafali
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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2
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Javeed S, Naeem MS, Awais M, Farooq A, Zulfiquar MK, Ahmad Khan F. Outcome of modified fleur-de-lis latissimus dorsi myocutaneous flap for breast reconstruction. Asian J Surg 2024; 47:2161-2167. [PMID: 38350776 DOI: 10.1016/j.asjsur.2024.01.125] [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: 04/08/2023] [Revised: 12/14/2023] [Accepted: 01/19/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Reconstruction of breast following mastectomy is important in terms of rehabilitating patients of breast cancer. Numerous approaches have been used in the reconstruction process. A procedure that has gained interest of the patients is reconstruction of breast using the autologous form. Main objective of this study is to determine the outcomes of modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction. METHODOLOGY This is a retrospective case series which was conducted at the Department of Plastic Surgery, SIMS/Services Hospital, Lahore, from January 2020 till December 2022. 184 patients age 25-60 years and Females with a history of mastectomy, who had to undergo creation of breast shape using a tissue flap from another part of the body at the site of breast following mastectomy were included. All patients were subjected to standard procedure of breast reconstruction with latissimus dorsi flap using modified fleur-de-lis technique and postoperatively weekly assessment in the first month and then monthly until 3 months was carried out and outcome of the study was analysed. RESULTS The mean age and VAS score of the patients was 49.7 ± 9.17 and 6 ± 2.21, respectively. 57.1 % patients have DCIS, benign in 38 % patients and other tumours were present in 4.9 % patients. Immediate versus delayed reconstruction was done in 63.6 % versus 36.4 % patients respectively. Good aesthetic outcome was achieved in 80.3 % patients CONCLUSION: Modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction yielded a good aesthetic outcome in the majority of the patients.
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Affiliation(s)
- Sundas Javeed
- Services Institute of Medical Sciences Lahore, Pakistan.
| | | | - Muhammad Awais
- Services Institute of Medical Sciences Lahore, Pakistan.
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3
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Awaida CJ, Bernier C, Bou-Merhi JS, Trabelsi NO, Gagnon A, El-Khatib A, Harris PG, Odobescu A. Staged Mastopexy before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Breast Reconstruction. Plast Reconstr Surg 2024; 153:864e-872e. [PMID: 37335584 DOI: 10.1097/prs.0000000000010823] [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: 06/21/2023]
Abstract
BACKGROUND Breast reconstruction following nipple-sparing mastectomy (NSM) in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes. METHODS A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before NSM and reconstruction in the authors' institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded. RESULTS In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3%) were reconstructed with free abdominal flaps, six (7.1%) with tissue expanders, and 66 (78.6%) with permanent subpectoral implants and acellular dermal matrix. There was one case of postoperative superficial nipple-areola complex epidermolysis (1.2%), and two cases of partial mastectomy skin flap necrosis (2.4%). The mean follow-up time after completion of reconstruction was 8.3 months. CONCLUSION Mastopexy or breast reduction before NSM and reconstruction is a safe procedure with a low risk of ischemic complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Cyril J Awaida
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Christina Bernier
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Joseph S Bou-Merhi
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | | | - Alain Gagnon
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Arij El-Khatib
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Patrick G Harris
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Andrei Odobescu
- Department of Plastic Surgery, University of Texas Southwestern
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4
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Shih L, Doval A, Burns HR, Kaplan J, Ellsworth WA, Chevray PM, Spiegel AJ, Friedman JD. Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg 2024; 91:249-257. [PMID: 38428233 DOI: 10.1016/j.bjps.2024.02.042] [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: 08/14/2023] [Revised: 11/27/2023] [Accepted: 02/04/2024] [Indexed: 03/03/2024]
Abstract
Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures.
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Affiliation(s)
- Linden Shih
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Andres Doval
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Heather R Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jordan Kaplan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Warren A Ellsworth
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Pierre M Chevray
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Aldona J Spiegel
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Jeffrey D Friedman
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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5
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Daly L, Tsai J, Stone K, Wapnir I, Karin M, Wan D, Momeni A. Nipple-areola-complex preservation and obesity-Successful in stages. Microsurgery 2024; 44:e31043. [PMID: 37013250 DOI: 10.1002/micr.31043] [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: 06/21/2022] [Revised: 01/12/2023] [Accepted: 03/09/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population. METHODS Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed. RESULTS Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission. CONCLUSIONS Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.
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Affiliation(s)
- Lauren Daly
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jacqueline Tsai
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Kim Stone
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Irene Wapnir
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Mardi Karin
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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6
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Varnava C, Bogusch M, Wellenbrock S, Hirsch T, Wiebringhaus P, Kueckelhaus M. Mastopexy Strategies for Ptotic Breasts in Patients Choosing Autologous Reconstruction Following Prophylactic Mastectomy. J Clin Med 2023; 12:jcm12093082. [PMID: 37176523 PMCID: PMC10178942 DOI: 10.3390/jcm12093082] [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: 02/19/2023] [Revised: 04/03/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Autologous breast reconstruction is a reliable solution for many patients after mastectomy. While this technique represents a standardized approach in many patients, patients with ptotic breasts may require a combination of procedures to achieve an aesthetically pleasing result. METHODS We reviewed the mastectomy and free-flap breast reconstruction procedures performed at our institution from 2018 to 2022 in patients with ptotic breasts. The technique used to address the ptosis was put in focus as we present the four strategies used by our reconstructive surgeons. We performed two different one-stage and two different two-stage procedures. The difference between the two-stage procedures was the way the nipple areola complex was treated (inferior dermal pedicle or free skin graft). The difference between the one-stage procedures was the time of execution of the mastopexy/breast reduction (before or after the mastectomy and autologous breast reconstruction). RESULTS The one-stage procedure was performed with a free NAC in three patients and with a pedicled NAC in five patients. The two-stage procedure was performed in seven patients, with six of them undergoing mastopexy before and one patient undergoing mastopexy after the bilateral mastectomy and autologous reconstruction. No flap loss or total loss of the nipple areola complex occurred. Partial NAC loss was observed in five breasts in the single-stage group without any occurrence in the double-stage group. CONCLUSIONS While both one- and two-stage procedures were performed in a safe fashion with satisfactory results at our institution, larger trials are required to determine which procedure may yield the best possible outcomes. These outcomes should also include oncological safety and patient-reported outcomes.
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Affiliation(s)
- Charalampos Varnava
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany
- Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany
| | - Miriam Bogusch
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany
| | - Sascha Wellenbrock
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany
- Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany
| | - Tobias Hirsch
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany
- Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany
| | - Philipp Wiebringhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany
- Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany
| | - Maximilian Kueckelhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, 48157 Muenster, Germany
- Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany
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7
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Karin MR, Pal S, Ikeda D, Silverstein M, Momeni A. Nipple Sparing Mastectomy Technique to Reduce Ischemic Complications: Preserving Important Blood Flow Based on Breast MRI. World J Surg 2023; 47:192-200. [PMID: 36207418 DOI: 10.1007/s00268-022-06764-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) with immediate breast reconstruction is commonly performed. However, nipple areolar complex (NAC) and mastectomy skin necrosis represent significant complications requiring reoperation and revision. Breast MRI, often obtained for oncologic assessment, can visualize the dominant breast and NAC vascular supply. This study describes the surgical technique utilizing breast MRI blood flow information to preserve important NAC blood supply, thereby, reducing ischemic complications. METHODS After IRB approval, a prospectively maintained database of all NSM by a single breast surgeon from 2018 to 2020 formed the study group. Preoperative contrast enhanced Breast MRI analysis determined the dominant NAC blood supply. Intraoperatively, the dominant Internal Mammary Artery Perforator (IMP) to the NAC was preserved (IMP-NSM). The IMP-NSM surgical technique preserving the IMP blood flow, evaluation of breast MRI blood flow patterns, surgical findings, and ischemic complications were analyzed. RESULTS 114 NSM were performed in 74 patients (mean age: 49 years [range, 22-73 years], BMI 25.8 kg/m2 [range, 19-41 kg/m2]). Breast MRI identified the dominant IMP to the NAC in 92%. IMP preservation was successful in 89% (101/114). Necrosis requiring NAC removal occurred in 0.9% (1/114), and skin necrosis reoperation in 1.8% (2/114). Including all post-operative necrosis occurred in 10.5% (12/114), statistically significantly lower compared to the literature for NSM assessing MRI blood flow data without surgical IMP preservation (necrosis 24.4%, p < 0.001) (Bahl et al. in J Am Coll Surg 223(2):279-285, 2016) utilizing Doppler for IMP preservation (necrosis 37%, p < 0.001) (Swistel et al. in Plast Reconstr Surg Glob Open 2(8):e198, 2014) and dividing the IMP in all (necrosis 31.4%, p < 0.001) (Ahn et al. in Eur J Surg Oncol 44(8):1170-1176, 2018). CONCLUSIONS The IMP-NSM surgical technique preserves the dominant blood supply to the NAC, thereby, decreasing ischemic complications.
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Affiliation(s)
- Mardi R Karin
- Division of General Surgery, Section of Surgical Oncology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Sunita Pal
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Debra Ikeda
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Max Silverstein
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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8
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Peled AW, Clavin NW. Novel Approaches to Breast Reconstruction. Surg Clin North Am 2022; 103:141-153. [DOI: 10.1016/j.suc.2022.08.008] [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]
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9
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Weinzierl A, Schmauss D, Harder Y. [The Value of Synthetic and Biologic Meshes in Implant-Based Breast Reconstruction]. HANDCHIR MIKROCHIR P 2022; 54:269-278. [PMID: 35944534 DOI: 10.1055/a-1830-8217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Implant based breast reconstruction (IBBR) keeps evolving and has been influenced heavily by the use of synthetic and biologic meshes in the last years. In both, subpectoral as well as prepectoral approaches the use of synthetic and biologic meshes has made it possible to place implants precisely according to the breast's footprint and strengthen soft-tissue coverage, particularly in the lower pole of the breast with lower complication rates and better cosmesis. Various mesh options that differ in material, processing, size and cost are currently in clinical use. This review aims to define the role of biologic and synthetic meshes in IBBR regarding the advantages and disadvantages of their use.
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Affiliation(s)
- Andrea Weinzierl
- Institut für Klinisch-Experimentelle Chirurgie, Universität des Saarlandes, Homburg/Saar, Deutschland
| | - Daniel Schmauss
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano (ORL), Ente Ospedaliero Cantonale (EOC), Lugano, Schweiz.,Fakultät der Biomedizinischen Wissenschaften, Università della Svizzera Italiana, Lugano, Schweiz
| | - Yves Harder
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano (ORL), Ente Ospedaliero Cantonale (EOC), Lugano, Schweiz.,Fakultät der Biomedizinischen Wissenschaften, Università della Svizzera Italiana, Lugano, Schweiz
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10
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Momeni A. [Hybrid Breast Reconstruction Following Mastectomy]. HANDCHIR MIKROCHIR P 2022; 54:297-304. [PMID: 35732188 DOI: 10.1055/a-1808-6779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6 S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i. e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.
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Affiliation(s)
- Arash Momeni
- Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Stanford, United States
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11
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Weinzierl A, Schmauss D, Brucato D, Harder Y. Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind? J Clin Med 2022; 11:jcm11113079. [PMID: 35683465 PMCID: PMC9181810 DOI: 10.3390/jcm11113079] [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: 05/02/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 01/15/2023] Open
Abstract
Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.
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Affiliation(s)
- Andrea Weinzierl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Germany;
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
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12
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The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction. Aesthetic Plast Surg 2022; 46:655-660. [PMID: 34845512 DOI: 10.1007/s00266-021-02660-2] [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: 08/08/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
Shared decision-making gives patients greater autonomy in their healthcare decisions; however, decisions that result in negative outcomes may lead to decision regret. The complexity of reconstructive options makes post-mastectomy breast reconstruction particularly prone to decision regret. This study's purpose was to explore the relationship between breast reconstruction modalities and degree of postoperative decision regret. Patients who had undergone either implant-based or autologous breast reconstruction with a minimum of 12 months of follow-up were invited to complete the Decision Regret Scale and the BREAST-Q Satisfaction with Breasts module. The impact of reconstructive modality and occurrence of postoperative complications on decision regret and satisfaction with breasts was examined. Sixty-three patients completed the questionnaires-25 patients with implant-based reconstruction and 38 patients with autologous reconstruction. The average Decision Regret score was 84.6 ± 23.6; thirty-one patients experienced no decision regret. The average score for the BREAST-Q module was 81.9 ± 18.8. Neither satisfaction with breasts nor decision regret were impacted by the reconstructive modality. The occurrence of postoperative complications was strongly correlated with lower Decision Regret scores (91.6 vs. 74.6, p=0.004) but was not correlated with lower Satisfaction with Breasts scores (84.6 vs. 78.2, p=0.18). Patients had relatively low levels of decision regret and relatively high levels of satisfaction with breasts, irrespective of reconstructive modality. Having a postoperative complication led to significantly greater levels of decision regret without impacting satisfaction with breasts. Patients may benefit from additional preoperative education on possible complications to mitigate decision regret. LEVEL OF EVIDENCE IV: 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 .
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13
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Impact of Incision Placement on Ischemic Complications in Microsurgical Breast Reconstruction. Plast Reconstr Surg 2022; 149:316-322. [PMID: 35077404 DOI: 10.1097/prs.0000000000008770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy is associated with greater patient satisfaction than non-nipple-sparing approaches. Although various nipple-sparing mastectomy incisions have been described, the authors hypothesized that incision location would impact the rate and location of ischemic complications to the mastectomy skin flap. METHODS A prospectively maintained database was queried to identify patients who underwent nipple-sparing mastectomy with immediate microsurgical reconstruction with a minimum postoperative follow-up of 12 months. The impact of incision location on postoperative ischemic complications was investigated. Major complications were defined as those that required reexploration in the operating room or inpatient management; minor complications were amenable to outpatient management. Multivariable logistic and linear regression were performed to investigate risk factors for postoperative complications following breast reconstruction. RESULTS Eighty-seven patients met inclusion criteria. The following nipple-sparing mastectomy incisions were used: radial with a periareolar extension (39 percent), inframammary fold (31 percent), vertical with a periareolar extension (22 percent), vertical (6 percent), and radial (2 percent). Seven patients (8 percent) had major complications, whereas twenty-six patients (29.9 percent) developed minor postoperative complications. Inframammary fold incisions were associated with significantly greater rates of mastectomy skin flap necrosis (p = 0.002), whereas periareolar incisions were associated with significantly greater rates of postoperative nipple-areola complex necrosis (p = 0.04). CONCLUSIONS The authors report a significant association between incision location and ischemic complications to the breast skin envelope in microsurgical breast reconstruction. The authors observed a significant association of inframammary fold and periareolar incisions with mastectomy skin flap and nipple-areola complex necrosis, respectively. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Gulcelik MA, Dogan L, Karaman N, Bahcecitapar M, Ozaslan C. Oncoplastic Level II Surgical Techniques for Breast Cancer Treatment: Long-Term Outcomes. Breast Care (Basel) 2022; 17:24-30. [PMID: 35355700 PMCID: PMC8914188 DOI: 10.1159/000514468] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/16/2021] [Indexed: 02/03/2023] Open
Abstract
Background Problems in patients who could not get adequate surgical margins (SM) and good cosmetic results with breast-conserving surgery (BCS) have been overcome with the introduction of oncoplastic surgery (OPS) methods. The purpose of this study was the documentation of level II techniques and the presentation of long-term survival results. Methods The data on patients who had been prospectively registered in the database between 2007 and 2017 and who had been treated with level II OPS due to invasive breast cancer were examined. Results A total of 1,074 patients were included in the study. The most commonly applied level II oncoplastic techniques were performed in the upper outer quadrantectomy with racquet incision in 334 (31%) patients, inferior pedicle flaps in 294 (27.3%), and vertical mammoplasty in 140 (13%). Reexcision was performed in 96 patients (8.9%). Total breast conservation rate was 96%. Five-year disease-free survival (DFS) was 88%, local recurrence-free survival (LRFS) 93.6%, and overall survival (OS) 96%. Ten-year DFS was 72%, LRFS 85.4%, and OS 90.2%. Conclusion Level II OPS techniques have low reoperation and complication rates and a high rate of breast protection. The success of these techniques has been demonstrated in terms of long-term local control. Awareness of the fact that many patients who undergo OPS will not lose their breasts should be created, and regular training programs for OPS techniques should be conducted especially in developing countries. By revealing these results, it is hoped that the OPS and breast conservation rates will increase.
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Affiliation(s)
- Mehmet Ali Gulcelik
- Department of Surgical Oncology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Lutfi Dogan
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey,*Lutfi Dogan, Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara 06200 (Turkey),
| | - Niyazi Karaman
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Melike Bahcecitapar
- Department of Statistics, Hacettepe University, Faculty of Science, Ankara, Turkey
| | - Cihangir Ozaslan
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey
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Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes. Plast Reconstr Surg 2021; 148:1173-1185. [PMID: 34644280 DOI: 10.1097/prs.0000000000008282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. METHODS A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. RESULTS Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. CONCLUSIONS Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Deptula P, Yesantharao P, Wapnir I, Nguyen D. Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study. Ann Plast Surg 2021; 86:S395-S402. [PMID: 33470622 DOI: 10.1097/sap.0000000000002725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage. METHODS We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure. RESULTS Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group. CONCLUSIONS Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.
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Affiliation(s)
- Peter Deptula
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Irene Wapnir
- Section of Surgical Oncology, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Dung Nguyen
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA
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Riis M. Management of patients with BRCA mutation from the point of view of a breast surgeon. Ann Med Surg (Lond) 2021; 65:102311. [PMID: 33996049 PMCID: PMC8091883 DOI: 10.1016/j.amsu.2021.102311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/24/2022] Open
Abstract
Germ-line mutation in BRCA (BReast CAncer gene) 1 or BRCA2 are found in 3–4% of all women with breast cancer. These patients have a significant increased risk of breast and ovarian cancer. They are often younger when diagnosed with the mutation, and the possible breast cancer they get is often aggressive with inferior outcome. There are risk reducing strategies, and the most powerful strategy is risk reducing surgery, both risk reducing bilateral mastectomy (RRM) and risk reducing bilateral salpino-oophorectomy (PBSO). This review is meant to address breast surgery in patients with germline BRCA mutation. The guidelines and techniques applied is under continuous change and it is important for the clinicians to be well informed to provide the patient with the information needed for them to make an informed decision on what risk strategy to choose. Patients with germ-line mutation in BRCA1 or BRCA2 have a significant increased risk of breast and ovarian cancer. There are different risk reducing strategies and the most powerful strategy is risk-reducing surgery, both risk reducing bilateral mastectomy and risk reducing bilateral salpingo-oophorectomy. Guidelines and techniques for the risk reducing surgery of the breast are under continuous change and improvement. Breast conserving therapy is not associated with worse survival and is a good option for a BRCA mutation carrier diagnosed with breast cancer. Risk-reducing mastectomy can be performed in a later setting. The management of BRCA mutation carriers, both affected and unaffected, should be performed in a multidisciplinary team. Physicians need to be systematically educated and updated on the most recent literature.
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