Batwing mammoplasty: a safe oncoplastic technique for breast conservation in breast cancer patients with gigantomastia

Investigating the relationship between sensation and satisfaction in reduction mammaplasty: A systematic review and meta-analysis

BACKGROUND

Reduction mammaplasties are among the plastic surgery procedures with the highest rates of patient satisfaction. However, the loss of postoperative sensation in the breast and nipple-areolar complex remains a concern. In light of increasing interest in nerve-preservation techniques, we sought to investigate the relationship between retained sensation with overall satisfaction in reduction mammaplasty in current literature.

METHODS

The authors systematically reviewed all studies that reported postoperative sensation and satisfaction in patients who underwent reduction mammaplasty, using the MEDLINE, Embase, Cochrane, CINAHL, and Scopus databases in October 2023. Studies were evaluated for methodological quality using an NIH Quality Assessment Tool. Meta-analyses of proportions were conducted.

RESULTS

A total of 48 studies met the eligibility criteria. The median quality assessment score was 8/10. For 28 studies eligible for statistical analysis, random effects pooled proportion for patients that retained preoperative sensation was 0.78 (95% CI: 0.67-0.87), and for patients that report postoperative satisfaction was 0.94 (95% CI: 0.91-0.97). Overall, the studies reported a relatively wide range of sensation outcomes with consistently high satisfaction scores.

CONCLUSION

The results of this systematic review suggest that other surgical factors (e.g., relief of macromastia symptoms, aesthetic appearance) play a greater role in patient satisfaction compared to sensation retention in reduction mammaplasty. Wide variability in assessment methodologies for both sensation and satisfaction was noted. Standardizing and objectifying measurement techniques, particularly for sensation, will help further characterize the relationship between sensation and satisfaction in future studies.

Extreme oncoplasty: past, present and future

Breast surgery has evolved from mastectomy to breast-conserving surgery (BCS). Breast oncoplastic surgery later emerged with the inclusion and development of techniques used in plastic surgery for breast neoplasms. Recently, a new paradigm has been considered for mastectomy candidates with large multifocal and multicentric tumours, designated extreme oncoplasty (EO), which has allowed new techniques to be applied to tumours that would have been ineligible for BCS before. There are few publications and no uniform descriptions grouping all the technical possibilities and new indications together. We performed this a review with the objective of evaluating the indications and surgeries performed in the EO context, representing a new perspective for BCS. We observed new indications as extensive microcalcifications, locally advanced breast carcinoma with partial response to chemotherapy, small to moderate-sized non-ptotic central tumours and extreme ptosis. Small breasts are able for EO since the presence of ptosis. New surgeries are reported as disguised geometric compensation, perforators flaps, local/regional flaps, latissimus dorsi miniflap and partial breast amputation. It is important to decrease barriers to oncoplastic surgery if we want to increase the use of EO and BCS rates.

Localization of Central Breast Lymphatics and Predefined Separation of Lobes along the Horizontal Septum

BACKGROUND

The predictable localization of the neurovascular supply along the ligamentous suspension, composed of the horizontal septum, vertical ligaments, and superficial fascia, has increased safety in breast reduction. Lymphatic drainage of the breast has always been described as running close to vascular supply. However, the correlation between the lymphatic course and ligamentous suspension has not yet been considered. This study aimed to visualize the relationship, direction of lymphatic flow, and predefined separation of lobes along the horizontal septum.

METHODS

To investigate central drainage, methylene blue was injected subareolarly in five breasts of female cadavers before blunt preparation of the horizontal septum in anatomical studies. To visualize central and peripheral drainage, lymphographin was injected into one of the three different sites in 14 breasts; the dynamic flow of drainage was observed during subsequent septum-based breast reductions in clinical settings.

RESULTS

In all anatomical studies, a predefined section of the glandular layers allowed access to central clearance along the stained horizontal septum. Clinical investigations similarly showed clearance along the corresponding part of the ligamentous suspension, most reliably along the horizontal septum. The affected quadrant of the breast, its relation to the nipple-areola complex, and the anterior-posterior axis toward the thoracic wall mainly determine the direction of lymphatic flow. Interconnections along the ligaments may explain the unpredictability of final clearance directions.

CONCLUSIONS

This study shows the horizontal septum as a guiding structure for central mammary drainage. This may encourage a septum-based approach for refinement of procedures such as oncoplastic, irradiation, and lymphedema treatments.

Preserving Nipple Sensitivity after Breast Cancer Surgery: A Systematic Review and Meta-Analysis

Purpose

As breast-conserving procedures become increasingly safe and viable options for surgical management of breast cancer, efforts have focused on assessing and optimizing patient-reported outcome measures (PROMs), such as nipple sensation. This study aims to evaluate the current understanding of nipple-areolar complex (NAC) sensation outcomes in breast cancer patients undergoing breast cancer surgeries, namely, nipple-sparing mastectomies (NSM), skin-sparing mastectomies (SSM), and lumpectomies.

Methods

Articles including terms related to "nipple," "mastectomy," "sensation," and "patient-reported outcome" were queried from three databases according to PRISMA guidelines. Study characteristics, patient demographics, and surgical details were recorded. Outcomes of interest included objective nipple sensitivity testing and PROMs.

Results

Of 888 manuscripts identified, 28 articles met the inclusion criteria. Twelve studies (n = 578 patients) used objective measures to evaluate sensitivity, such as monofilament testing. Sixteen studies (n = 1785 patients) assessed PROMs through validated or investigator-generated surveys. Three of the included studies reported NAC sensitivity in patients who received NSM with neurotization (n = 203 patients) through a variety of techniques that used various grafts to coapt a lateral intercostal nerve to the NAC nerve stumps. Results of investigator surveys showed that of 1565 patients without neurotization, nipple sensation was maintained in 29.0% (n = 453) of patients. Of 138 NSM patients without NAC neurotization, SWM testing showed an average loss of protective sensation in the nipple (average SWM score: 4.7) compared to normal or diminished sensation to light touch in nonoperated controls (average SWM score: 2.9, n = 195). Of patients who underwent NSM with neurotization, one study (n = 78) reported maintenance of NAC sensation in 100% of patients, while another study (n = 7) reported average diminished protective sensation in the nipple (average SWM score: 3.9).

Conclusion

Our study has shown that objective and patient-reported results of nipple sensitivity support nipple-sparing techniques as a viable option for preserving NAC sensation, although patients can expect a decrease in sensation overall. Neurotization of the NAC during NSM shows promising results of improved postoperative nipple sensitivity, though additional studies are warranted to confirm this finding. Variations between study methodologies highlight the lack of standardization in sensory testing techniques when evaluating NAC sensation.

The Tumor Plastic Surgery Technology versus Traditional Repair Technology on the Repair of Large-Area Skin Defects after Maxillofacial Tumor Resection: A Randomized Controlled Trial

Objective

To explore the effect of tumor plastic surgery on the repair of large-area skin defects after maxillofacial tumor resection.

Methods

90 patients undergoing maxillofacial tumor resection in our hospital from March 2019 to March 2020 were selected and randomized 1 : 1 to receive either tumor plastic surgery (experimental group) or traditional repair (control group). The clinical efficacy and facial cosmetic improvement of the two groups were compared. The Patient and Observer Scar Assessment Scale (POSAS) was used to evaluate the surgical outcomes of the two groups, the Profile of Mood States (POMS) was used to evaluate the patients' psychological status, and the Generic Quality of Life Inventory-74 (GQOLI-74) was used to assess the quality of life of patients.

Results

Total clinical effective rate of the experimental group was significantly higher than that of the control group (p < 0.001). A higher excellent rate of facial cosmetic improvement was observed in the experimental group versus the control group (p < 0.001). Significantly lower POSAS scores of the experimental group than the control group were observed (p < 0.001). The POMS scores of the experimental group after treatment were lower than those of the control group (p < 0.001). Tumor plastic surgery resulted in a remarkably higher GQOLI-74 score in the patients versus traditional repair (p < 0.001).

Conclusion

Tumor plastic surgery is a promising alternative for patients undergoing maxillofacial tumor resection. It can effectively promote the recovery of facial morphology and physiological function of patients, with high clinical efficacy, so it merits promotion and application.

Outcome reporting in therapeutic mammaplasty: a systematic review

BACKGROUND

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

METHODS

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

RESULTS

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

CONCLUSION

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.