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King CA, Shaposhnik G, Sayyed AA, Bartholomew AJ, Bozzuto LM, Sosin M, Greenwalt IT, Fan KL, Song D, Tousimis EA. Expanded Indications for Nipple-Sparing Mastectomy and Immediate Breast Reconstruction in Patients Older Than 60 Years. Ann Plast Surg 2024; 92:279-284. [PMID: 38394268 DOI: 10.1097/sap.0000000000003750] [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: 02/25/2024]
Abstract
INTRODUCTION Although nipple-sparing mastectomy (NSM) and immediate breast reconstruction (IBR) have long been praised for excellent cosmetic results and the resultant psychosocial benefits, the feasibility and safety of these procedures in patients older than 60 years have yet to be demonstrated in a large population. METHODS Patients undergoing NSM with or without IBR at the MedStar Georgetown University Hospital between 1998 and 2017 were included. Patient demographics, surgical intervention, and complication and recurrence events were retrieved from electronic medical records. Primary outcomes were recurrence and complication rates by age groups older and younger than 60 years. RESULTS There were 673 breasts from 397 patients; 58 (8.6%) older than 60 years and 615 (91.4%) younger than 60 years with mean follow-up of 5.43 (0.12) years. The mean age for those older than 60 was 63.9 (3.3) years, whereas that for those younger than 60 was 43.1 (7.9) years (P < 0.001). The older than 60 group had significantly higher prevalence of diabetes, rates of therapeutic (vs prophylactic) and unilateral (vs bilateral) NSM, and mastectomy weight. However, there were no significant differences by age group in complication rates or increased risk of locoregional or distant recurrence with age. CONCLUSIONS Based on similar complication profiles in both age groups, we demonstrate safety and feasibility of both NSM and IBR in the aging population. Despite increased age and comorbidity status, appropriately selected older women were able to achieve similar outcomes to younger women undergoing NSM with or without IBR.
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Affiliation(s)
| | - Guy Shaposhnik
- From the Division of Breast Surgery, Department of Surgery
| | - Adaah A Sayyed
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Laura M Bozzuto
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael Sosin
- Plastic Surgery Arts of NJ, Private Practice, New Brunswick, NJ
| | | | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - David Song
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eleni A Tousimis
- Department of Breast Surgical Oncology, Cleveland Clinic Indian River Hospital, Vero Beach, FL
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2
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Apostolova C, Ferroum A, Alhassan B, Prakash I, Viezel-Mathieu A, Basik M, Boileau JF, Meterissian S, Wong N, Foulkes WD, Wong SM. Surgical Decision Making in Genetically High-Risk Women: Quantifying Postoperative Complications and Long-Term Risks of Supplemental Surgery After Risk-Reducing Mastectomy. Ann Surg Oncol 2024; 31:356-364. [PMID: 37838650 DOI: 10.1245/s10434-023-14418-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/25/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Risk-reducing mastectomy (RRM) helps prevent breast cancer in high-risk women but also carries a risk of unanticipated supplemental surgeries. We sought to determine the likelihood of supplemental surgeries following RRM. METHODS We performed a retrospective cohort study of female patients with a confirmed germline pathogenic variant (GPV) in a breast cancer susceptibility gene (BRCA1/2, PALB2 and others) who underwent bilateral or contralateral RRM at our institution between 2006 and 2022. Supplemental surgeries were defined as any operation requiring general or local anesthesia performed outside of the initially planned procedure(s). The Kaplan-Meier method was used to estimate the 5-years cumulative incidence of supplemental surgery. RESULTS Of 560 GPV carriers, RRMs were performed in 258 (46.1%) women. The median age of the cohort was 44 years (interquartile range 37-52 years), with 33 (12.8%) patients undergoing RRM without reconstruction and 225 (87.2%) undergoing RRM with reconstruction. Following surgery, 34 patients (13.2%) developed early (< 30 days) postoperative complications, including infection, hematoma, seroma, loss of the nipple areola complex, flap necrosis, implant exposure and/or prosthesis removal. At a median follow-up of 3.8 years, 94 (36.4%) GPV carriers underwent at least one reoperation. Participants who experienced an early postoperative complication had the highest rate of reoperation (85.3% vs. 29.0%; p < 0.001) and a significantly higher likelihood of multiple additional surgical interventions (41.2% vs. 10.7%; p < 0.001). The 5-years rate of supplemental surgery was 39.2% [95% confidence interval (CI) 32.7-46.5] in the overall cohort and 31.5% (95% CI 24.9-39.3) in patients without an early postoperative complication. CONCLUSIONS Unanticipated supplemental surgeries occur in 40% of GPV carriers following RRM and in nearly one-third of patients without early postoperative complications.
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Affiliation(s)
- Carla Apostolova
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Amina Ferroum
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Basmah Alhassan
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Ipshita Prakash
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Alex Viezel-Mathieu
- Department of Plastic and Reconstructive Surgery, McGill University Medical School, Montreal, QC, Canada
| | - Mark Basik
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | | | - Sarkis Meterissian
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
| | - Nora Wong
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
- Department of Human Genetics, McGill University Medical School, Montreal, QC, Canada
| | - William D Foulkes
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada
- Department of Human Genetics, McGill University Medical School, Montreal, QC, Canada
| | - Stephanie M Wong
- Department of Surgery, McGill University Medical School, Montreal, QC, Canada.
- Stroll Cancer Prevention Centre, Segal Cancer Centre, Jewish General Hospital, Montreal, QC, Canada.
- Department of Oncology, McGill University Medical School, Montreal, QC, Canada.
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Tevlin R, Sharma AD, Griffin M, Wan D, Momeni A. Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction. Aesthetic Plast Surg 2023; 47:2351-2359. [PMID: 37704858 DOI: 10.1007/s00266-023-03616-4] [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: 06/14/2023] [Accepted: 08/10/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Pre-pectoral implant-based breast reconstruction (IBR) is becoming increasingly popular, permitting optimal implant positioning on the chest wall, prevention of animation deformity, and reduced patient discomfort. There are, however, concerns related to increased rates of breast implant rippling in pre-pectoral (versus submuscular) IBR, which can prompt a patient to seek revisionary surgery. The aim of this study is to identify factors that can be implemented to reduce implant rippling in the setting of pre-pectoral IBR. METHODS A literature review was conducted using the PubMed database to determine the rate of rippling in pre-pectoral IBR. Clinical studies in English were included. Further review was then performed to explore technical strategies associated with reduced rates of rippling in pre-pectoral two-stage breast reconstruction. RESULTS Implant rippling has been reported with a rate varying from 0 to 53.8% in 25 studies of pre-pectoral IBR (including both direct-to-implant and two-stage IBR). The majority of studies reviewed did not demonstrate a significant association between BMI and rippling, suggesting that other factors, likely technical and device-related, contribute to the manifestation of implant rippling. Hence, we explored whether specific technical modifications could be implemented that would reduce the risk of rippling in patients undergoing pre-pectoral IBR. Specifically, we highlight the need for close attention to expansion protocol and pocket dimension, expander fill medium and implant characteristics, and the rationale behind adjunctive procedures to reduce implant rippling. CONCLUSION Surgical modifications may reduce the incidence of rippling in pre-pectoral breast reconstruction. LEVEL OF EVIDENCE V 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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Affiliation(s)
- Ruth Tevlin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
- Royal College of Surgeons in Ireland, St Stephen's Green, Dublin, Ireland
| | - Ayushi Dutt Sharma
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Michelle Griffin
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA
- Royal College of Surgeons in Ireland, St Stephen's Green, Dublin, Ireland
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Palo Alto, CA, 94304, USA.
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Vingan PS, Kim M, Rochlin D, Allen RJ, Nelson JA. Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose? Surg Oncol Clin N Am 2023; 32:761-776. [PMID: 37714642 DOI: 10.1016/j.soc.2023.05.007] [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] [Indexed: 09/17/2023]
Abstract
Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.
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Affiliation(s)
- Perri S Vingan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Danielle Rochlin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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5
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Francis SD, Thawanyarat K, Johnstone TM, Yesantharao PS, Kim TS, Rowley MA, Sheckter CC, Nazerali RS. How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5040. [PMID: 37325376 PMCID: PMC10263246 DOI: 10.1097/gox.0000000000005040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023]
Abstract
Infection after implant-based breast reconstruction adversely affects surgical outcomes and increases healthcare utilization. This study aimed to quantify how postimplant breast reconstruction infections impact unplanned reoperations, hospital length of stay, and discontinuation of initially desired breast reconstruction. Methods We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction). Results In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001). Conclusions Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.
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Affiliation(s)
| | - Kometh Thawanyarat
- Medical College of Georgia at Augusta University, AU/UGA Medical Partnership, Athens, Ga
| | | | - Pooja S Yesantharao
- Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | | | - Mallory A Rowley
- State University of New York, Upstate Medical University, Syracuse, N.Y
| | - Clifford C Sheckter
- Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Rahim S Nazerali
- Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
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Ostapenko E, Nixdorf L, Devyatko Y, Exner R, Math P, Wimmer K, Haeusler T, Fitzal F. Ptotic versus Nonptotic Breasts in Nipple-sparing Mastectomy and Immediate Prepectoral Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5032. [PMID: 37250830 PMCID: PMC10219702 DOI: 10.1097/gox.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/06/2023] [Indexed: 05/31/2023]
Abstract
In recent years, nipple-sparing mastectomy followed by implant-based breast reconstruction has gained popularity due to improved cosmetic and psychological benefits. However, patients with ptotic breasts remain the main challenge for surgeons, owing to the potential risk of postoperative complications. Methods A retrospective chart review was performed for patients who underwent nipple-sparing mastectomy and prepectoral implant-based breast reconstruction between March 2017 and November 2021. Patient demographics, incidence of complications, and quality of life assessed using the BREAST-Q questionnaire were compared between the two different incisions [inverted-T for ptotic versus inframammary fold (IMF) for nonptotic breasts]. Results A total of 98 patients were examined: 62 in the IMF cohort and 36 in the inverted-T cohort. The results demonstrated equivalence in the safety metrics between the two groups, including hematoma (p=0.367), seroma (p=0.552), infection (P = 1.00), skin necrosis (P = 1.00), local recurrence (P = 1.00), implant loss (P = 0.139), capsular contracture (P = 1.00), and nipple-areolar complex necrosis (P = 0.139). The BREAST-Q scores were equally high in both groups. Conclusion Our results suggest that inverted-T incision for ptotic breasts is a safe modality with similar complication rates and high aesthetic results compared with IMF incision for nonptotic breasts. A higher rate of nipple-areolar complex necrosis in the inverted-T group, although not significant, should be considered during careful preoperative planning and patient selection.
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Affiliation(s)
- Edvin Ostapenko
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Larissa Nixdorf
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Yelena Devyatko
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ruth Exner
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Pia Math
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kerstin Wimmer
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Theresa Haeusler
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Florian Fitzal
- From the Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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7
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Correction of Rippling in Implant-based Breast Reconstruction with Serratus Fascia Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4862. [PMID: 36910739 PMCID: PMC10005828 DOI: 10.1097/gox.0000000000004862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/24/2023] [Indexed: 03/12/2023]
Abstract
Implant-based breast reconstruction represents the most popular procedure for the treatment of women undergoing skin-sparing mastectomy. In selected patients, it allows for obtaining an excellent appearance of the reconstructed breast with great satisfaction to the patient. However, aesthetic and functional results can be affected by complications requiring reoperation. Among them, rippling is an undesired occurrence associated with implant-based reconstruction. It consists of a cutaneous manifestation, visible and/or palpable, of the implant wrinkles and edge which appear mostly when the patient leans forward. To treat this contour deformity, several techniques have been described such as acellular dermal matrices and autologous tissues. In this study, we intend to add the serratus anterior fascial flap within the autologous options in the treatment of implant rippling, reporting our experience.
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8
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Cogliandro A, Salzillo R, Barone M, Tenna S, Cagli B, Persichetti P. Direct-to-Implant Breast Reconstruction After Unilateral and Bilateral Mastectomy: Cross-Sectional Study of Patient Satisfaction and Quality of Life with BREAST-Q. Aesthetic Plast Surg 2023; 47:43-49. [PMID: 35927501 DOI: 10.1007/s00266-022-02986-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/04/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Immediate single stage breast reconstruction is a challenging procedure with the goal of improving the quality of life of patients with breast cancer. The aim of this study is to evaluate using the BREAST-Q patient satisfaction, body perception and quality of life after direct-to-implant breast reconstruction comparing unilateral and bilateral reconstructions. METHODS In this study we enrolled 56 women who underwent mastectomy and immediate single-stage direct-to-implant (DTI) breast reconstruction at Campus Bio-Medico University of Rome between 2013 and 2020. One year after surgery they were administered electronically the BREAST-Q post-operative module. RESULTS Our two cohorts of patients consisted in 34 women who received unilateral nipple-sparing mastectomy and DTI breast reconstruction and 22 women who underwent bilateral nipple-sparing mastectomy and DTI breast reconstruction. Twenty-four of the 34 patients belonging to the unilateral group responded to the questionnaire (70.5%), while in the bilateral group responders were 16 out of 22 (72.7%). The BREAST-Q scores were compared between the two groups: patients undergoing bilateral mastectomy and breast reconstruction showed higher scores in every BREAST-Q domain compared to patients undergoing unilateral mastectomy and breast reconstruction with a statistically significant difference in the Satisfaction with breast (P = 0.01), Sexual well-being (P = 0.03), and Satisfaction with implants (P = 0.01) domains. CONCLUSIONS Patients undergoing bilateral DTI breast reconstruction have a favorable postoperative surgical cosmetic outcome with a better patient's body image perception and a higher post-operative level of satisfaction compared to unilateral DTI reconstruction after nipple-sparing mastectomy. 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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Affiliation(s)
- Annalisa Cogliandro
- Plastic and Reconstructive Surgery Unit, Medico University of Rome, Campus BioVia Alvaro del Portillo 200, Rome, Italy. .,Research group "To be and to appear: Objective indication to Plastic Surgery", Medico University in Rome, Campus Bio, Rome, Italy.
| | - Rosa Salzillo
- Plastic and Reconstructive Surgery Unit, Medico University of Rome, Campus BioVia Alvaro del Portillo 200, Rome, Italy
| | - Mauro Barone
- Plastic and Reconstructive Surgery Unit, Medico University of Rome, Campus BioVia Alvaro del Portillo 200, Rome, Italy.,Research group "To be and to appear: Objective indication to Plastic Surgery", Medico University in Rome, Campus Bio, Rome, Italy
| | - Stefania Tenna
- Plastic and Reconstructive Surgery Unit, Medico University of Rome, Campus BioVia Alvaro del Portillo 200, Rome, Italy
| | - Barbara Cagli
- Plastic and Reconstructive Surgery Unit, Medico University of Rome, Campus BioVia Alvaro del Portillo 200, Rome, Italy
| | - Paolo Persichetti
- Plastic and Reconstructive Surgery Unit, Medico University of Rome, Campus BioVia Alvaro del Portillo 200, Rome, Italy.,Research group "To be and to appear: Objective indication to Plastic Surgery", Medico University in Rome, Campus Bio, Rome, Italy
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9
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Ostapenko E, Nixdorf L, Devyatko Y, Exner R, Wimmer K, Fitzal F. Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction: A Systemic Review and Meta-analysis. Ann Surg Oncol 2023; 30:126-136. [PMID: 36245049 PMCID: PMC9726796 DOI: 10.1245/s10434-022-12567-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) remains the standard and most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral IBBR has resurged in popularity, despite limited data comparing prepectoral with subpectoral IBBR. METHODS A systematic search of PubMed and Cochrane Library from January 1, 2011 to December 31, 2021, was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guidelines, data were extracted by independent reviewers. Studies that compared prepectoral with subpectoral IBBR for breast cancer were included. RESULTS Overall, 15 studies with 3,101 patients were included in this meta-analysis. Our results showed that patients receiving prepectoral IBBR experienced fewer capsular contractures (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.32-0.92; P = 0.02), animation deformity (OR, 0.02; 95% CI, 0.00-0.25; P = 0.002), and prosthesis failure (OR, 0.58; 95% CI, 0.42-0.80; P = 0.001). There was no significant difference between prepectoral and subpectoral IBBR in overall complications (OR, 0.83; 95% CI, 0.64-1.09; P = 0.19), seroma (OR, 1.21; 95% CI, 0.59-2.51; P = 0.60), hematoma (OR, 0.76; 95% CI, 0.49-1.18; P = 0.22), infection (OR, 0.87; 95% CI, 0.63-1.20; P = 0.39), skin flap necrosis (OR, 0.70; 95% CI, 0.45-1.08; P = 0.11), and recurrence (OR, 1.31; 95% CI, 0.52-3.39; P = 0.55). Similarly, no significant difference was found in Breast-Q scores between the prepectoral and subpectoral IBBR groups. CONCLUSIONS The results of our systematic review and meta-analysis demonstrated that prepectoral, implant-based, breast reconstruction is a safe modality and has similar outcomes with significantly lower rates of capsular contracture, prosthesis failure, and animation deformity compared with subpectoral, implant-based, breast reconstruction.
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Affiliation(s)
- Edvin Ostapenko
- Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria ,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Larissa Nixdorf
- Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Yelena Devyatko
- Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Ruth Exner
- Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Kerstin Wimmer
- Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Florian Fitzal
- Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
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10
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Chinta S, Koh DJ, Sobti N, Packowski K, Rosado N, Austen W, Jimenez RB, Specht M, Liao EC. Cost analysis of pre-pectoral implant-based breast reconstruction. Sci Rep 2022; 12:17512. [PMID: 36266370 PMCID: PMC9582390 DOI: 10.1038/s41598-022-21675-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 09/29/2022] [Indexed: 01/12/2023] Open
Abstract
With improvement in mastectomy skin flap viability and increasing recognition of animation deformity following sub-pectoral implant placement, there has been a transition toward pre-pectoral breast reconstruction. While studies have explored the cost effectiveness of implant-based breast reconstruction, few investigations have evaluated cost with respect to pre-pectoral versus sub-pectoral breast reconstruction. A retrospective review of 548 patients who underwent mastectomy and implant-based breast reconstruction was performed from 2017 to 2020. The demographic and surgical characteristics of the pre-pectoral and sub-pectoral cohorts were well matched, except for reconstructive staging, as patients who underwent pre-pectoral reconstruction were more likely to undergo single-stage instead of two-stage reconstruction. Comparison of institutional cost ratios by reconstructive technique revealed that the sub-pectoral approach was more costly (1.70 ± 0.44 vs 1.58 ± 0.31, p < 0.01). However, further stratification by laterality and reconstructive staging failed to demonstrate difference in cost by reconstructive technique. These results were confirmed by multivariable linear regression, which did not reveal reconstructive technique to be an independent variable for cost. This study suggests that pre-pectoral breast reconstruction is a cost-effective alternative to sub-pectoral breast reconstruction and may confer cost benefit, as it is more strongly associated with direct-to-implant breast reconstruction.
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Affiliation(s)
- Sachin Chinta
- grid.189504.10000 0004 1936 7558Boston University School of Medicine, Boston, MA USA
| | - Daniel J. Koh
- grid.189504.10000 0004 1936 7558Boston University School of Medicine, Boston, MA USA
| | - Nikhil Sobti
- grid.40263.330000 0004 1936 9094Department of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Kathryn Packowski
- grid.32224.350000 0004 0386 9924Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 435, Boston, MA 02114 USA
| | - Nikki Rosado
- grid.32224.350000 0004 0386 9924Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 435, Boston, MA 02114 USA
| | - William Austen
- grid.32224.350000 0004 0386 9924Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 435, Boston, MA 02114 USA
| | - Rachel B. Jimenez
- grid.32224.350000 0004 0386 9924Division of Radiation Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Michelle Specht
- grid.32224.350000 0004 0386 9924Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Eric C. Liao
- grid.32224.350000 0004 0386 9924Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 435, Boston, MA 02114 USA
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11
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Prepectoral Breast Reconstruction without Acellular Dermal Matrix: Have We Come Full Circle? J Pers Med 2022; 12:jpm12101619. [PMID: 36294758 PMCID: PMC9605327 DOI: 10.3390/jpm12101619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Breast reconstruction is an integral part of breast cancer treatment [...].
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12
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Scardina L, Di Leone A, Biondi E, Carnassale B, Sanchez AM, D’Archi S, Franco A, Moschella F, Magno S, Terribile D, Gentile D, Fabi A, D’Angelo A, Barone Adesi L, Visconti G, Salgarello M, Masetti R, Franceschini G. Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience. J Pers Med 2022; 12:jpm12091533. [PMID: 36143318 PMCID: PMC9504024 DOI: 10.3390/jpm12091533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. Results: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. Conclusions: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.
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Affiliation(s)
- Lorenzo Scardina
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Multidisciplinary Breast Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Correspondence: or
| | - Alba Di Leone
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Ersilia Biondi
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Beatrice Carnassale
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Alejandro Martin Sanchez
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Sabatino D’Archi
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Franco
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesca Moschella
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Stefano Magno
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Daniela Terribile
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Damiano Gentile
- Breast Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandra Fabi
- Precision Medicine Breast Unit, Scientific Directorate, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Anna D’Angelo
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Division of Breast Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Liliana Barone Adesi
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giuseppe Visconti
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Marzia Salgarello
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Riccardo Masetti
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Gianluca Franceschini
- Breast Unit, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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13
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Gahm J, Ljung Konstantinidou A, Lagergren J, Sandelin K, Glimåker M, Johansson H, Wickman M, de Boniface J, Frisell J. Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2231583. [PMID: 36112378 PMCID: PMC9482055 DOI: 10.1001/jamanetworkopen.2022.31583] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Multiple-dose antibiotic prophylaxis is widely used to prevent infection after implant-based breast reconstruction despite the lack of high-level evidence regarding its clinical benefit. OBJECTIVE To determine whether multiple-dose antibiotic prophylaxis is superior to single-dose antibiotic prophylaxis in preventing surgical site infection (SSI) after implant-based breast reconstruction. DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, randomized clinical superiority trial was conducted at 7 hospitals (8 departments) in Sweden from April 25, 2013, to October 31, 2018. Eligible participants were women aged 18 years or older who were planned to undergo immediate or delayed implant-based breast reconstruction. Follow-up time was 12 months. Data analysis was performed from May to October 2021. INTERVENTIONS Multiple-dose intravenous antibiotic prophylaxis extending over 24 hours following surgery, compared with single-dose intravenous antibiotic. The first-choice drug was cloxacillin (2 g per dose). Clindamycin was used (600 mg per dose) for patients with penicillin allergy. MAIN OUTCOMES AND MEASURES The primary outcome was SSI leading to surgical removal of the implant within 6 months after surgery. Secondary outcomes were the rate of SSIs necessitating readmission and administration of intravenous antibiotics, and clinically suspected SSIs not necessitating readmission but oral antibiotics. RESULTS A total of 711 women were assessed for eligibility, and 698 were randomized (345 to single-dose and 353 to multiple-dose antibiotics). The median (range) age was 47 (19-78) years for those in the multiple-dose group and 46 (25-76) years for those in the single-dose group. The median (range) body mass index was 23 (18-38) for the single-dose group and 23 (17-37) for the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of SSI. Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%), and 190 women (27.7%) received oral antibiotics because of clinically suspected SSI. There was no significant difference between the randomization groups for the primary outcome implant removal (odds ratio [OR], 1.26; 95% CI, 0.69-2.65; P = .53), or for the secondary outcomes readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65-2.15; P = .58) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51-1.02; P = .07). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05-2.55; P = .03). CONCLUSIONS AND RELEVANCE The findings of this randomized clinical trial suggest that multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing SSI and implant removal after implant-based breast reconstruction but comes with a higher risk of adverse events associated with antibiotic treatment. TRIAL REGISTRATION EudraCT 2012-004878-26.
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Affiliation(s)
- Jessica Gahm
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anna Ljung Konstantinidou
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St Göran’s Hospital, Stockholm, Sweden
| | - Jakob Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St Göran’s Hospital, Stockholm, Sweden
| | - Kerstin Sandelin
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Glimåker
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marie Wickman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Health Promotion Science, Sophiahemmet University, Stockholm, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St Göran’s Hospital, Stockholm, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
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14
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Wow T, Kolacinska-Wow A, Wichtowski M, Boguszewska-Byczkiewicz K, Nowicka Z, Ploszka K, Pieszko K, Murawa D. A Retrospective Study Assessing the Outcomes of Immediate Prepectoral and Subpectoral Implant and Mesh-Based Breast Reconstruction. Cancers (Basel) 2022; 14:cancers14133188. [PMID: 35804960 PMCID: PMC9264839 DOI: 10.3390/cancers14133188] [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: 04/30/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Introduction: In response to patient concerns about breast cancer recurrence, increased use of breast magnetic resonance imaging and genetic testing, and advancements in breast reconstruction techniques, mastectomy rates have been observed to rise over the last decade. The aim of the study is to compare the outcomes of prepectoral and subpectoral implants and long-term, dual-stage resorbable mesh-based breast reconstructions in mutation carriers (prophylactic surgery) and breast cancer patients. (2) Patients and methods: This retrospective, two-center study included 170 consecutive patients after 232 procedures: Prepectoral surgery was performed in 156 cases and subpectoral was performed in 76. (3) Results: Preoperative chemotherapy was associated with more frequent minor late complications (p < 0.001), but not major ones (p = 0.101), while postoperative chemotherapy was related to more frequent serious (p = 0.005) postoperative complications. Postoperative radiotherapy was associated with a higher rate of minor complications (31.03%) than no-radiotherapy (12.21%; p < 0.001). Multivariate logistic regression found complications to be significantly associated with an expander (OR = 4.43), skin-reducing mastectomy (OR = 9.97), therapeutic mastectomy vs. risk-reducing mastectomy (OR = 4.08), and postoperative chemotherapy (OR = 12.89). Patients in whom prepectoral surgeries were performed demonstrated significantly shorter median hospitalization time (p < 0.001) and lower minor complication rates (5.77% vs. 26.32% p < 0.001), but similar major late complication rates (p = 0.915). (4) Conclusions: Implant-based breast reconstruction with the use of long-term, dual-stage resorbable, synthetic mesh is a safe and effective method of breast restoration, associated with low morbidity and good cosmesis. Nevertheless, prospective, multicenter, and long-term outcome data studies are needed to further evaluate the benefits of such treatments.
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Affiliation(s)
- Thomas Wow
- Department of General Surgery and Surgical Oncology, Faculty of Medicine and Health Sciences, University of Zielona Gora, Zyty 26, 65-046 Zielona Gora, Poland; (T.W.); (M.W.); (K.P.); (D.M.)
| | - Agnieszka Kolacinska-Wow
- Department of Oncological Physiotherapy, Medical University of Lodz, Paderewskiego 4, 93-509 Lodz, Poland
- Breast Cancer Unit, Department of Surgical Oncology, Cancer Center, Copernicus Memorial Hospital, Paderewskiego 4, 93-509 Lodz, Poland;
- Correspondence: ; Tel.: +48-42-689-54-61
| | - Mateusz Wichtowski
- Department of General Surgery and Surgical Oncology, Faculty of Medicine and Health Sciences, University of Zielona Gora, Zyty 26, 65-046 Zielona Gora, Poland; (T.W.); (M.W.); (K.P.); (D.M.)
| | - Katarzyna Boguszewska-Byczkiewicz
- Breast Cancer Unit, Department of Surgical Oncology, Cancer Center, Copernicus Memorial Hospital, Paderewskiego 4, 93-509 Lodz, Poland;
| | - Zuzanna Nowicka
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Kosciuszki 4, 92-215 Lodz, Poland; (Z.N.); (K.P.)
| | - Katarzyna Ploszka
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Kosciuszki 4, 92-215 Lodz, Poland; (Z.N.); (K.P.)
| | - Karolina Pieszko
- Department of General Surgery and Surgical Oncology, Faculty of Medicine and Health Sciences, University of Zielona Gora, Zyty 26, 65-046 Zielona Gora, Poland; (T.W.); (M.W.); (K.P.); (D.M.)
- Department of Plastic Surgery and Burns, Hospital of Nowa Sol, Chalubinskiego 7, 67-100 Nowa Sol, Poland
| | - Dawid Murawa
- Department of General Surgery and Surgical Oncology, Faculty of Medicine and Health Sciences, University of Zielona Gora, Zyty 26, 65-046 Zielona Gora, Poland; (T.W.); (M.W.); (K.P.); (D.M.)
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15
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Weber WP, Shaw J, Pusic A, Wyld L, Morrow M, King T, Mátrai Z, Heil J, Fitzal F, Potter S, Rubio IT, Cardoso MJ, Gentilini OD, Galimberti V, Sacchini V, Rutgers EJT, Benson J, Allweis TM, Haug M, Paulinelli RR, Kovacs T, Harder Y, Gulluoglu BM, Gonzalez E, Faridi A, Elder E, Dubsky P, Blohmer JU, Bjelic-Radisic V, Barry M, Hay SD, Bowles K, French J, Reitsamer R, Koller R, Schrenk P, Kauer-Dorner D, Biazus J, Brenelli F, Letzkus J, Saccilotto R, Joukainen S, Kauhanen S, Karhunen-Enckell U, Hoffmann J, Kneser U, Kühn T, Kontos M, Tampaki EC, Carmon M, Hadar T, Catanuto G, Garcia-Etienne CA, Koppert L, Gouveia PF, Lagergren J, Svensjö T, Maggi N, Kappos EA, Schwab FD, Castrezana L, Steffens D, Krol J, Tausch C, Günthert A, Knauer M, Katapodi MC, Bucher S, Hauser N, Kurzeder C, Mucklow R, Tsoutsou PG, Sezer A, Çakmak GK, Karanlik H, Fairbrother P, Romics L, Montagna G, Urban C, Walker M, Formenti SC, Gruber G, Zimmermann F, Zwahlen DR, Kuemmel S, El-Tamer M, Vrancken Peeters MJ, Kaidar-Person O, Gnant M, Poortmans P, de Boniface J. Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy. Breast 2022; 63:123-139. [PMID: 35366506 PMCID: PMC8976143 DOI: 10.1016/j.breast.2022.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 12/31/2022] Open
Abstract
Aim Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario. Methods A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology. Results The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR. Conclusions The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR Autologous breast reconstruction is increasingly preferred over implants in the setting of radiation therapy. Use of patient-reported outcomes is endorsed. Shape and size of reconstructed breasts can hinder radiotherapy planning. There is a need for randomised phase III trials.
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Affiliation(s)
- Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Jane Shaw
- Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Andrea Pusic
- Brigham and Women's/Dana Farber Cancer Center, USA
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Monica Morrow
- Breast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tari King
- Department of Surgery, Brigham and Women's Hospital / Dana Farber Cancer Institute, USA
| | - Zoltán Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Jörg Heil
- Department of Obstetrics and Gynecology, University of Heidelberg, Medical School, Heidelberg, Germany
| | - Florian Fitzal
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Shelley Potter
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Clifton, Bristol, UK
| | - Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Maria-Joao Cardoso
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, And Nova Medical School, Lisbon, Portugal
| | | | | | - Virgilio Sacchini
- Breast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emiel J T Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - John Benson
- Cambridge Breast Unit, Addenbrooke's Hospital Cambridge, Cambridge, UK; Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation TRUST, School of Medicine, Anglia Ruskin University, Cambridge, UK
| | - Tanir M Allweis
- Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Martin Haug
- Breast Center and Department of Plastic, Reconstructive, Aesthetic and Handsurgery University Hospital Basel, University of Basel, Basel, Switzerland
| | - Regis R Paulinelli
- Federal University of Goiás, Araújo Jorge Hospital, Goiás Anti-Cancer Association, Goiás, Brazil
| | - Tibor Kovacs
- Jiahui Internatioonal Hospital Shanghai, China; Guy's and St. Thomas' NHS Foundation Trust London, UK
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | | | - Eduardo Gonzalez
- Departament of Mastology, Breast Unit- Instituto de Oncología Angel H Roffo, Buenos Aires Univesity. Buenos Aires, Argentina
| | - Andree Faridi
- Department of Senology/Breast Center, University Hospital Bonn, Germany
| | - Elisabeth Elder
- Westmead Breast Cancer Institute, Westmead Hospital, University of Sydney, Australia
| | - Peter Dubsky
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Breast Center, Hirslanden Clinic St. Anna, Lucerne, Switzerland
| | - Jens-Uwe Blohmer
- Department of Gynecology and Breast Center, Charité University Hospital, Berlin, Germany
| | - Vesna Bjelic-Radisic
- Breast Unit, Helios University Hospital, University Witten/Herdecke, Wuppertal, Germany
| | - Mitchel Barry
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Susanne Dieroff Hay
- Patient Advocacy Group, Oncoplastic Breast Consortium, President, the Swedish Breast Cancer Association, Stockholm, Sweden
| | - Kimberly Bowles
- Patient Advocacy Group, Oncoplastic Breast Consortium, Not Putting on A Shirt, Pittsburgh, USA
| | - James French
- Westmead Breast Cancer Institute, Westmead Hospital, University of Sydney, Australia
| | - Roland Reitsamer
- Breast Center Salzburg, University Clinic Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Rupert Koller
- Department of Plastic, Aesthetic and Reconstructive Surgery, Vienna Health Services, Clinic Landstrasse and Clinic Ottakring, Vienna, Austria
| | - Peter Schrenk
- Breast Cancer Center, Kepler University Hospital, Linz, Austria
| | | | - Jorge Biazus
- Division of Breast Surgery, Universidade Federal Do Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil
| | - Fabricio Brenelli
- Breast Oncology Division, University of Campinas, Campinas, São Paulo, Brazil
| | - Jaime Letzkus
- San Borja Arriaran Clinical Hospital, University of Chile, Chile
| | | | | | - Susanna Kauhanen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ulla Karhunen-Enckell
- Tampere University Hospital, Department of Surgery and Tays Cancer Center, Tampere, Finland
| | - Juergen Hoffmann
- Breast Center, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery - Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Heidelberg, Germany
| | - Thorsten Kühn
- Interdisciplinary Breast Center, Klinikum Esslingen, Germany
| | | | - Ekaterini Christina Tampaki
- Department of Plastic, Reconstructive Surgeryand Burn Unit, KAT Athens Hospital and Trauma Center, Athens, Greece
| | | | - Tal Hadar
- Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Giuseppe Catanuto
- Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | | | - Linetta Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Pedro F Gouveia
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, And Nova Medical School, Lisbon, Portugal
| | - Jakob Lagergren
- Department of Surgery, Capio St Goran's Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Tor Svensjö
- Department of Surgery, Central Hospital, Kristianstad, Sweden
| | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Elisabeth A Kappos
- Breast Center and Department of Plastic, Reconstructive, Aesthetic and Handsurgery University Hospital Basel, University of Basel, Basel, Switzerland
| | | | | | - Daniel Steffens
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Janna Krol
- Breast Center, University Hospital Basel, Basel, Switzerland
| | | | | | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Maria C Katapodi
- University of Basel, Basel, Switzerland; Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Susanne Bucher
- Breast Center, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Rosine Mucklow
- Patient Advocacy Group, Oncoplastic Breast Consortium, Basel, Switzerland
| | - Pelagia G Tsoutsou
- University Hospital Geneva, University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Atakan Sezer
- Department of Surgery, Trakya University Medical School Hospital, Turkey
| | - Güldeniz Karadeniz Çakmak
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | | | - Patricia Fairbrother
- Patient Advocacy Group, Oncoplastic Breast Consortium, Breakthrough Breast Cancer, Association Breast Surgery UKBCC, Kedleston, UK
| | - Laszlo Romics
- Department of Surgery, New Victoria Hospital, Glasgow, UK
| | - Giacomo Montagna
- Breast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cicero Urban
- Breast Unit, Hospital Nossa Senhora Das Graças, Curitiba, Brazil
| | - Melanie Walker
- Breast Endocrine and General Surgery Unit, The Alfred, Melbourne, Australia; Breast Surgeons of Australia and New Zealand (BreastSurgANZ), Australia
| | - Silvia C Formenti
- Department of Radiation Oncology and Meyer Cancer Center, Weill Cornell Medicine, USA
| | - Guenther Gruber
- Institute for Radiotherapy, Klinik Hirslanden, 8032, Zurich, Switzerland; University of Berne, 3000, Bern, Switzerland
| | - Frank Zimmermann
- Clinic of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - Daniel Rudolf Zwahlen
- Department of Radiation Oncology, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Sherko Kuemmel
- Department of Gynecology and Breast Center, Charité University Hospital, Berlin, Germany; Breast Unit, Kliniken Essen-Mitte, Germany
| | - Mahmoud El-Tamer
- Breast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marie Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Orit Kaidar-Person
- Breast Radiation Therapy Unit, Sheba Tel Hashomer, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Philip Poortmans
- Iridium Netwerk and University of Antwerp, Wilrijk-Antwerpen, Belgium
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
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Harvey KL, Sinai P, Mills N, White P, Holcombe C, Potter S. Short-term safety outcomes of mastectomy and immediate prepectoral implant-based breast reconstruction: Pre-BRA prospective multicentre cohort study. Br J Surg 2022; 109:530-538. [PMID: 35576373 PMCID: PMC10364707 DOI: 10.1093/bjs/znac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/18/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here. METHODS Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection. RESULTS Some 347 women underwent 424 immediate implant-based reconstructions at 40 centres. Most were single-stage direct-to-implant (357, 84.2 per cent) biological mesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction. CONCLUSION Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction.
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Affiliation(s)
- Kate L Harvey
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Parisa Sinai
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Nicola Mills
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | | | - Shelley Potter
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
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