Evaluation of Contralateral and Bilateral Prophylactic Mastectomy and Reconstruction Outcomes: Comparing Alloplastic and Autologous Reconstruction

Free Tissue Transfer for Reconstruction After Bilateral Skin Sparing Mastectomy-A Systematic Review

BACKGROUND

Breast cancer is the most commonly diagnosed malignant neoplasia in females worldwide. Overall survival and patients' choice for bilateral mastectomy have increased. It is therefore important to offer breast reconstructive procedures to improve patient quality of life and self-esteem. The aim of this systematic literature review is to quantify the outcome and sustainability of bilateral breast reconstruction using autologous, vascularized free tissue transfer.

METHODS

A systematic literature review of PubMed, Cochrane, and the Web of Science databases was performed. A total of 5879 citations were identified, and 12 studies met the inclusion criteria.

RESULTS

A total of 1316 patients were included, with a mean age of 47.2 years. Overall, 32.5% of patients experienced a complication after breast reconstruction. If reported, 7.45% of patients experienced major complications, while 20.7% had minor complications.The following flaps were used for breast reconstruction, in order of reducing frequency: DIEP (45.45%), TRAM (22.73%), SIEA (9.09%), SGAP (9.09%), TUG (4.55%), TMG (4.55%), and LD/MLD (4.55%).

CONCLUSIONS

Current studies indicate that bilateral breast reconstruction using autologous, vascularized free tissue transfer is a safe procedure for postmastectomy reconstruction and offers stable long-term results. This is particularly in comparison to implant-based breast reconstruction.

Do Corporate Payments Influence Research Related to the Use of Acellular Dermal Matrices in Breast Surgery?

BACKGROUND

No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs.

METHODS

The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database.

RESULTS

Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure.

CONCLUSIONS

Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery.

[Techniques and complications of non-genetic risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

Based on an updated review of the international literature covering the different surgical techniques and complications of risk reducing mastectomies (RRM) in non-genetic context, the Commission of Senology (CS) of the College National des Gynécologues Obstétriciens Français (CNGOF) aimed to establish recommendations on the techniques to be chosen and their implementation.

DESIGN

The CNGOF CS, composed of 24 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The CS adhered to and followed the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted.

METHODS

The CS considered 6 questions in 4 thematic areas, focusing on oncologic safety, risk of complications, aesthetic satisfaction and psychological impact, and preoperative modalities.

RESULTS

The application of the GRADE method resulted in 7 recommendations, 6 with a high level of evidence (GRADE 1±) and 1 with a low level of evidence (GRADE 2±).

CONCLUSION

There was significant agreement among the CS members on recommendations for preferred surgical techniques and practical implementation.

Latest Advancements in Autologous Breast Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses.

SUMMARY

Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.

Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia

OBJECTIVES

Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia.

MATERIALS AND METHODS

Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed.

RESULTS

Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%).

CONCLUSION

The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.

Breast Reconstruction with a Lateral Breast Free Flap: A New Application of Breast-sharing

Supplemental Digital Content is available in the text.

Breast reconstruction using contralateral autologous tissue, also known as breast sharing, is a viable option previously described in the literature, whereby flaps based on perforators of the internal mammary artery (internal mammary artery pedicle) are used. We report a postoncological breast reconstruction case using a microvascular flap taken from the lateral pole of the contralateral breast. We highlight the importance of preserving the medial pole of the donor breast for improving cosmesis, avoiding symmastia, and preserving the intermammary sulcus, as a difference with flaps based on the internal mammary artery pedicle flaps. Breast sensation could be recovered by neurotization of the lateral intercostal nerve, which may be included in the contralateral breast flap to be transferred. Contralateral breast free flaps could be an alternative to reconstruct the breast in selected patients. Oncological risk factors are discussed. Advances in genetic testing and tumor cell biology could help us to select the accurate candidates for this reconstructive technique.

The Goldilocks technique: An alternative method to construct a breast mound after prosthetic breast reconstruction failure

The Goldilocks technique for breast reconstruction utilizes redundant mastectomy flap tissue to construct a breast mound. This technique is suitable for women who decline, or are poor candidates for, traditional postmastectomy reconstruction. Moreover, this technique can be applied in secondary operations after the failure of initial reconstruction efforts. A 74-year-old patient underwent the Goldilocks procedure after reconstruction failure with an implant and acellular dermal matrix. At her 6-month follow-up, the cosmetic outcome of the procedure was satisfactory, and no complications were noted. Therefore, the Goldilocks procedure is a safe alternative to reconstruct breast mounds following reconstruction failure, especially in obese patients.

Patient-Reported Satisfaction after Prophylactic Operations of the Breast

Background

Prophylactic mastectomies in carriers of mutations in BRCA1 or BRCA2 are becoming increasingly more accepted. We investigated the outcome after prophylactic mastectomy, especially regarding satisfaction with the procedure, in a monocenter study.

Methods

BRCA1/2 mutation carriers and non-carriers with elevated pedigree-based cancer risk were followed prospectively in a structured surveillance program between 2000 and 2017. A retrospective telephone survey was conducted among all patients with documented prophylactic mastectomy. Complications and satisfaction with the decision for prophylactic mastectomy were recorded.

Results

39 patients who opted for a prophylactic mastectomy (38 BRCA1/2 mutation carriers and 1 non-carrier) were interviewed. Mostly nipple-sparing mastectomy with reconstruction was performed (87%). Half of the patients (22/39; 56.4%) had a history of unilateral breast cancer. The median time since prophylactic mastectomy was 5.6 years. While 61.5% did not report any complications, flap loss was seen in 15% (3/20) and moderate limitations in everyday life were present in 20% (7/35). An improvement in quality of life was noticed by 82% after prophylactic mastectomy and no patient expressed regret with regard to the decision.

Conclusions

Prophylactic mastectomy is a procedure with risk for long-term complications in some cases. Our results confirm high satisfaction with the decision and improved quality of life.