Reduction mammaplasty and mastopexy in previously irradiated breasts

Does Prior Breast Irradiation Increase Complications of Subsequent Reduction Surgery in Breast Cancer Patients? A systematic Review and Meta-Analysis

BACKGROUND

Reduction mammoplasty and mastopexy are potentially complicated by prior breast irradiation as part of breast conserving therapy. Associated tissue changes with therapeutic irradiation have led to surgeons deciding the risks may outweigh potential benefit for those patients. A systematic review of the existing literature was performed to explore surgical outcomes of patients undergoing delayed bilateral reduction mammoplasty or mastopexy following unilateral breast irradiation as part of breast conserving therapy.

METHODS

Medline, PubMed and EMBASE were searched from 1990 to 2023 according to PRISMA guidelines. Studies were combined by the generic inverse variance method on the natural logarithms of rate ratios (RR) using a random effect model in Review manager 5.4.1.

RESULTS

Fifteen studies reported outcomes in 188 patients who underwent breast reduction (BR) following unilateral breast conserving surgery and radiotherapy. The median age at BR was 51.5 years (range 39-60), and median time since radiotherapy was 48 months (range 11.7-86). We compared outcomes for irradiated breast (IB) versus non-irradiated breast (NIB). Pooled results showed higher rate of major complications in the IB (RR 2.52, 95%CI 0.96-6.63, p=0.06), but not statistically significant. However, rate of minor complications was significantly higher in the IB (RR 3.97 95%CI 1.86-8.50, p<0.0004). Incidence of fat necrosis as a discrete complication was 2× higher in IB (RR 2.14 95%CI 0.85-5.35, p-value 0.10) compared to the NIB, but not significant.

CONCLUSION

We found breast reduction to be safe with acceptable risk of major complications. However, the overall complication rate remains higher in IB compared to NIB.

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 .

Risk Factors and Complications in Reduction Mammaplasty: A Systematic Review and Meta-analysis

BACKGROUND

Reduction mammaplasty (RM) has become established as the standard effective method for treating macromastia, but reports on the risk factors that predispose to postoperative complications have been conflicting. This meta-analysis aimed to pool the available data to identify predictors of complications following RM.

METHODS

The PubMed, Web of Science, Embase, and Cochrane databases were screened from inception to 1 Jan 2022, and studies were included based on predefined criteria. The perioperative risk factors BMI, smoking, age, diabetes, radiation therapy, and tissue resection weight were extracted and their correlation with complications assessed.

RESULTS

A total of 40 studies comprising of 5908 patients were included. BMI ≥ 30kg/m2 (OR = 1.65, 95% CI 1.35-2.02; p < 0.01) and ≥ 40 kg/m2 (OR = 1.97, 95% CI 1.26-3.08; p < 0.01), smoking (OR = 2.57, 95% CI 2.01-3.28; p < 0.01), diabetes (OR = 2.21, 95% CI 1.19-4.07; p < 0.05), a unilateral resection weight ≥ 1000 g (OR = 1.76, 95% CI 1.02-3.05; p < 0.05), and radiation therapy (OR = 11.11, 95% CI 2.01-3.28; p < 0.01) were associated with higher rates of postoperative complications. Obese patients (BMI ≥ 30 kg/m2) were more likely to experience fat necrosis (OR = 3.00, 95% CI 1.37-6.57; p < 0.01) and infection (OR = 1.66, 95% CI 1.15-2.40; p < 0.05). Smokers had a 2.03 times higher risk of infection (95% CI 1.24-3.31; p < 0.01) and 2.34 times higher risk of dehiscence (95% CI 1.38-3.98; p < 0.01). No association between complication occurrence and age 40 or 50 years or total tissue resection weight ≥ 1000 g was identified.

CONCLUSIONS

This meta-analysis provides evidence that obesity, smoking, diabetes, unilateral resection weight ≥ 1000 g, and preoperative radiation therapy predispose to complication occurrence in RM. This information can optimize the ability of surgeons to provide preoperative patient education, perioperative assessment, and postoperative care planning.

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 .

Safety of Reduction Mammaplasty and Mastopexy After Breast Conservation Therapy and Radiation Therapy: A Case Series

BACKGROUND

Conservative surgery and radiotherapy (CS + RT) have become the standard of care for early-stage breast cancer as an alternative to mastectomy. With the increasing rate of obesity and incidence of macromastia, surgeons increasingly encounter patients with a history of breast radiation desiring breast reduction. However, elective breast surgery after irradiation remains to be controversial due to known adverse effects of radiation, especially on wound healing, and unknown effects of lumpectomy on traditional pedicle choices. Herein, we present our experiences and outcomes of reduction mammaplasties and mastopexies in patients with breast cancer previously treated with CS + RT.

METHODS

Between 2009 and 2020, 13 patients undergoing reduction mammaplasty or mastopexy, who have previously underwent CS + RT with or without axillary surgery, were included in this study. Surgical techniques and complications, including delayed wound healing, infection, fat necrosis, and nipple-areolar necrosis, were recorded and analyzed based on the irradiated versus nonirradiated sides.

RESULTS

Of the 13 patients, delayed wound healing occurred in 7% on the irradiated side and 15% on the nonirradiated sides (P > 0.05). No significant correlation was observed between the number of complications and time of elective breast surgery from the last radiation therapy. Complications between irradiated and nonirradiated breasts did not significantly differ in both the reduction mammaplasty and mastopexy groups.

CONCLUSIONS

Reduction mammaplasty and mastopexy in patients with a history of lumpectomy and breast irradiation can be safely performed and should be considered in those experiencing macromastia or asymmetry post-CS + RT.

Inferior Pedicle Reduction Mammoplasty as Corrective Surgery after Breast Conserving Surgery and Radiation Therapy

Background/Aim—Twenty patients had corrective reconstruction surgery by means of a reduction mammaplasty or mastopexy after a previous BCS (Breast Conserving Surgery) and RT (Radiation Therapy); the risk factors and post-operative complications were reported in order to define a safe and effective technique for reduction mammaplasty in previously irradiated breast cancer patients. Materials and Methods—From June 2011 to December 2019, 20 pts. were operated on at the Breast Surgery Clinic of San Martino Policlinic Hospital, Genoa, Italy. Pre- and post-operative parameters included clinic-pathological features of the primary tumor; a lapse of time from primary radio-surgery; the extent of follow-up; the rate of post-operative wound infections; the persistence of breast asymmetry, and a post-operative patient satisfaction index by means of a BREAST-Q questionnaire. Results—Three patients (15%) developed minor complications in the irradiated breast, but no complication was observed into the non-irradiated breast. No statistically significant correlation was found between the post-operative complications and the risk factors. The statistical analysis of BREAST-Q questionnaire responses gave an average patient’s satisfaction index that was equal to 90.8/100 (range: 44 to 100). Conclusions—Inferior pedicle reduction mammoplasty is an effective reduction mammoplasty technique in regard to the extent of breast tissues that are to be removed both in irradiated and contralateral breast; moreover, the incidence of post-operative complications is clearly limited when a careful technique is adopted, and it can be reasonably applied also in patients with co-morbidity factors.

Delayed Mastopexy Following Breast-Conserving Surgery and Radiation Therapy: A Case-Control Study to Evaluate Safety and Versatility of the Central Mound Technique

INTRODUCTION

Breast remodeling following breast-conserving surgery (BCS) and radiation therapy (RT) is challenging and often burdened by complications due to irradiated tissue atrophy. The authors present a case-control study to compare the central mound mastopexy (CMM) to more conventional techniques, applying it to different patterns of skin excision.

METHODS

A variation of the original central mound technique is presented separately addressing glandular and cutaneous deformities. Between 2012 and 2018, 17 consecutive patients presenting defects following unilateral BCS and RT underwent breast remodeling with CMM technique. Immediate and long-term complications together with patient-reported outcomes were evaluated and compared to a matched control group of sixteen patients who underwent superior pedicle mammoplasty. Two independent plastic surgeons reviewed pre- and postoperative photographs and rated the cosmetic outcomes on a visual analog scale from 1 to 5.

RESULTS

In the study group, different patterns of skin excision, i.e., inverted-T pattern (41.2%), circumareolar (23.5%), skin-sparing type V (17.65%), omega (11.77%), and J (5.88%), were used to correct various breast deformities, and a decisional algorithm was developed. No major complications were registered. Retraction recurrence rate was higher in the control group (p = 0.037). Cosmetic results were considered more satisfying in the CMM group by both patients (4.18 vs 3.00, p<0.001) and surgeons (4.06 vs 2.69, p=0.001).

CONCLUSIONS

The CMM technique is an advanced approach that addresses breast remodeling after BCS-RT surgery yielding reliable results. Following our algorithm, several patterns of skin excision, tailored to pre-existing scars, can be considered and safely performed.

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 .

A Simple Technique to Correct Lumpectomy Deformities Using Free Nipple Grafting

BACKGROUND

Lumpectomy followed by radiation can lead to severe breast asymmetry. Many surgeons are hesitant to perform traditional mastopexies on irradiated breasts due to increased complication rates. An alternative approach to achieve breast symmetry is presented. This technique consists of free nipple-areola complex (NAC) grafting of the irradiated breast to a higher position and primary closure of the donor site, in an appropriate fashion without undermining, followed by a formal mastopexy of the nonradiated breast.

OBJECTIVE

To evaluate the outcomes of free NAC grafting, used as an alternative method to achieve breast symmetry, in patients who underwent lumpectomy with radiation.

METHODS

A case series of 5 patients who underwent breast revision using this technique, performed by a single surgeon from 2017 to 2019 (n = 5), is presented.

PATIENT DEMOGRAPHICS

All patients had history of lumpectomy followed by radiation therapy. The average age was 59.2 years, average BMI was 33.0. Three of 5 patients had a significant smoking history. The average time between radiation and surgery was 5.9 years.

RESULTS

The average operating time was 141.8 minutes. The average follow-up period was 5.8 months. Two (40%) of the free NAC grafts were complicated by hypopigmentation of the reconstructed NAC. No major complications were reported, and no patients required return to the operating room. All patients had successful outcomes with improved breast symmetry.

CONCLUSIONS

Free NAC grafting of irradiated breasts and contralateral mastopexy may be a reliable alternative to achieve breast symmetry, with a less invasive approach, in patients who underwent lumpectomy and radiation.

No-Scar Breast Reduction Utilizing Power-Assisted Liposuction Mammaplasty, Loops, and Lipofilling

BACKGROUND

In continued interest to develop and refine minimally invasive procedures, recent publications reported a scarless approach in breast lifting.

OBJECTIVES

The authors sought to describe a power-assisted lipomodeling technique combined with surgical loops to achieve breast reduction and reshaping with minimal scars.

METHODS

Between 2014 and 2018, 94 patients underwent breast reduction by combined liposuction and loops. Following infiltration of the breasts, liposuction of the outer quadrants and the lower pole was achieved to reduce the breast footprint and the lateral and inferior heaviness of the breast. After multiaxial multiplanar tunnelization, 3 types of loops were taken around the breast to suspend and elevate the breast skin envelope and parenchyma. Each loop was guided through a 3-mm, 3-hole cannula passed through skin stab incisions. The first loop was designed to reduce the breast footprint and enhance the breast projection, whereas the second loop was designed to achieve breast conus remodeling. The third loop was passed circumferentially around the areola and then cephalad along the breast axis and pulled until the desired nipple-areola complex elevation was reached. Each loop was pulled to achieve the desired breast projection and shape.

RESULTS

The authors achieved breast reduction with a mean nipple elevation of 7.3 cm, and 88% of patients were satisfied with their breast shape. The total complication rate was 1%, including mild cellulitis in 1 breast, treated efficiently with oral antibiotics.

CONCLUSIONS

The proposed technique is a novel, simple, and safe alternative to achieve breast reduction and reshaping without a scar.

LEVEL OF EVIDENCE: 4

Reduction mammoplasty and mastopexy in the previously irradiated breast - a systematic review and meta-analysis

Breast cancer is the most common cancer diagnosed in women, and early stages are treated with lumpectomy and irradiation. Irradiation, however, leads to reduced vascularization and fibrosis, which may influence the cosmetic outcome unfavourably and increase complications after subsequent surgery on irradiated breasts. Patients with significant asymmetry after treatment may desire corrective reduction mammoplasty or mastopexy, but this may be associated with increased complication rates. This systematic review and meta-analysis aimed to investigate postoperative complication rates after bilateral reduction mammoplasty or mastopexy in women who had undergone unilateral lumpectomy and irradiation. PubMed, Medline, EMBASE and Cochrane databases were searched for eligible studies. After screening titles and abstracts, 14 full text studies were reviewed, and 7 of these were included in the analysis. The meta-analysis showed a significantly higher complication rate in the irradiated breast compared to the non-irradiated breast, rate ratio 4.82 (95% CI: 1.58, 14.70), p = 0.006. The complication rate was 54% in the irradiated breast (58/107) compared to 8% (9/107) in the non-irradiated breast (p = 0.034). This study suggests that reduction mammoplasty or mastopexy in the previously irradiated breast is associated with a significantly increased risk of complications. Careful patient selection and information are paramount in the treatment of this patient group.

Assessment and Treatment Outcomes of Persistent Radiation-Induced Alopecia in Patients With Cancer

Importance

Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described.

Objective

To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma.

Design, Setting, and Participants

A retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA.

Main Outcomes and Measures

The clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans.

Results

Of the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, -0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (-0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction.

Conclusions and Relevance

Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.

Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast

Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.

[Mastopexy]

Mastopexy is one of the most popular cosmetic surgery procedures. Complications are rare but imperfections in results can occur. The main imperfections affect the nipple-areolar complex, the volume of the segment II, the progression of the segment III as well as the cicatrization. We will consider the different techniques to prevent or treat them in case of occurrence.

Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned

BACKGROUND

Breast conservation therapy (BCT) can cause breast distortion and asymmetry. Repair of this asymmetry by means of breast reduction or mastopexy procedures can be challenging and harbor considerably high rates of complications.

METHODS

In this retrospective study, we describe our experience in repairing post-BCT breast asymmetry by performing breast reduction or mastopexy. The surgical protocol we followed consisted of stringent patient selection, thorough surgical planning, basic surgical refinements, and patient education for enhancing the likelihood of achieving a good outcome with minimal surgical complications.

RESULTS

Our search of the departmental database identified 25 patients with breast asymmetry who had undergone breast reduction or mastopexy between 2009 and 2017. Corrective surgery was performed 4 years on average after the completion of radiotherapy, and those patients included eleven who had undergone breast reduction and fourteen who had undergone mastopexy on the radiated side. Two patients (8%) had major complications that required further surgery (major fat necrosis, wound infection, and breast deformation), and five patients (20%) had minor complications (infection, minor fat necrosis, wound dehiscence, and nipple congestion). All complications developed on the radiated breast. There was no correlation between the occurrence of complications and patients' demographics, tumor type, tumor location, and breast tissue resection (p > 0.05).

CONCLUSION

Only two of our 25 patients had major complications following breast reduction and mastopexy for the repair of asymmetry post-BCT. Following our four-step protocol was instrumental in leading to the successful performance of these procedures.

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 .