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Villanueva K, Patel H, Ghosh D, Klomhaus A, Slack G, Festekjian J, Da Lio A, Tseng C. A Single-center Comparison of Surgical Outcomes following Prepectoral and Subpectoral Implant-based Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5880. [PMID: 38859804 PMCID: PMC11163997 DOI: 10.1097/gox.0000000000005880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/17/2024] [Indexed: 06/12/2024]
Abstract
Background Prepectoral implant placement continues to gain widespread acceptance as a safe and effective option for breast reconstruction. Current literature demonstrates comparable rates of complications and revisions between prepectoral and subpectoral placement; however, these studies are underpowered and lack long-term follow-up. Methods We performed a retrospective cohort study of patients who underwent immediate two-staged tissue expander or direct-to-implant breast reconstruction at a single center from January 2017 to March 2021. Cases were divided into prepectoral and subpectoral cohorts. The primary outcomes were postoperative complications, aesthetic deformities, and secondary revisions. Descriptive statistics and multivariable regression models were performed to compare the demographic characteristics and outcomes between the two cohorts. Results We identified 996 breasts (570 patients), which were divided into prepectoral (391 breasts) and subpectoral (605 breasts) cohorts. There was a higher rate of complications (P < 0.001) and aesthetic deformities (P = 0.02) with prepectoral breast reconstruction. Secondary revisions were comparable between the two cohorts. Multivariable regression analysis confirmed that prepectoral reconstruction was associated with an increased risk of complications (odds ratio 2.39, P < 0.001) and aesthetic deformities (odds ratio 1.62, P = 0.003). Conclusions This study evaluated outcomes in patients undergoing prepectoral or subpectoral breast reconstruction from a single center with long-term follow-up. Prepectoral placement was shown to have an inferior complication and aesthetic profile compared with subpectoral placement, with no difference in secondary revisions. These findings require validation with a well-designed randomized controlled trial to establish best practice for implant-based breast reconstruction.
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Affiliation(s)
- Karie Villanueva
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, Calif
| | - Harsh Patel
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, Calif
| | - Durga Ghosh
- Los Angeles David Geffen School of Medicine, University of California, Los Angeles, Calif
| | - Alexandra Klomhaus
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, Calif
| | - Ginger Slack
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, Calif
| | - Jaco Festekjian
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, Calif
| | - Andrew Da Lio
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, Calif
| | - Charles Tseng
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, Calif
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Talwar AA, Lanni MA, Ryan IA, Kodali P, Bernstein E, McAuliffe PB, Broach RB, Serletti JM, Butler PD, Fosnot J. Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes. Plast Reconstr Surg 2024; 153:281e-290e. [PMID: 37159266 DOI: 10.1097/prs.0000000000010618] [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: 05/10/2023]
Abstract
BACKGROUND Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center. METHODS Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions. RESULTS A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months. CONCLUSIONS Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Ankoor A Talwar
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Michael A Lanni
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Isabel A Ryan
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Pranav Kodali
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Elizabeth Bernstein
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Phoebe B McAuliffe
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Robyn B Broach
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Joseph M Serletti
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Paris D Butler
- Division of Plastic Surgery, Department of Surgery, Yale Medicine
| | - Joshua Fosnot
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
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Cho MJ, Farhadi RV, Nash DW, Kaleeny J, Povoski SP, Chao AH. The current use of tissue expanders in breast reconstruction: device design, features, and technical considerations. Expert Rev Med Devices 2024; 21:27-35. [PMID: 38032224 DOI: 10.1080/17434440.2023.2288911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION The use of tissue expanders (TE) in post-mastectomy breast reconstruction is a widely accepted practice, especially in patients desiring implant-based breast reconstruction. It has become the standard of care to perform a two-staged breast reconstruction using tissue expanders for the past 50 years due to its reliability, safety, cost-effectiveness, and versatility. Due to its popularity, there are numerous types and features of breast tissue expanders and various surgical approaches available for plastic surgeons. AREAS COVERED In this article, we will review the role of tissue expanders in breast reconstruction, the types and features of breast tissue expanders, and technical considerations. EXPERT OPINION The use of tissue expanders in breast reconstruction offers significant advantages of preserving the breast skin envelope and reestablishing the breast mound. With evolving approaches to breast reconstruction, tissue expander design, and application underwent several refinements and modifications. Due to these advances, studies on its long-term efficacy and safety profile typically fall behind and more studies with higher levels of evidence are needed to better evaluate the efficacy and safety profile of tissue expanders. With increased understanding, reconstructive surgeons can minimize complications and maximize reconstructive, aesthetic outcomes with high patient satisfaction.
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Affiliation(s)
- Min-Jeong Cho
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rana V Farhadi
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - David W Nash
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph Kaleeny
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Albert H Chao
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Park JS, Jin US. Improvement of Shoulder Motion in Two-Stage Dual-Plane Implant-Based Breast Reconstruction followed by Radiation Therapy through Delayed Prepectoral Conversion. Arch Plast Surg 2024; 51:52-61. [PMID: 38425848 PMCID: PMC10901588 DOI: 10.1055/s-0043-1775591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/04/2023] [Indexed: 03/02/2024] Open
Abstract
Background Although prepectoral implant-based breast reconstruction has recently gained popularity, dual-plane reconstruction is still a better option for patients with poor-quality mastectomy skin flaps. However, shoulder morbidity is aggravated by subpectoral reconstruction, especially in irradiated patients. This study aimed to demonstrate shoulder exercise improvement in subpectoral reconstruction by delayed prepectoral conversion with an acellular dermal matrix (ADM) inlay graft technique at the time of expander-to-implant exchange after irradiation. Methods Patients with breast cancer treated for expander-to-implant exchange after subpectoral expander insertion and subsequent radiotherapy between January 2021 and June 2022 were enrolled. An ADM inlay graft was inserted between the pectoralis major muscle and the previously inserted ADM. The ADM was sutured partially overlapping the pectoralis muscle from the medial side with the transition part, to the muscle border at the lateral side. Perioperative shoulder joint active range-of-motion (ROM) for forward flexion, abduction, and external rotation was also evaluated. Results A total of 35 patients were enrolled in the study. Active shoulder ROM significantly improved from 163 degrees preoperatively to 176 degrees postoperatively in forward flexion, 153 to 175 degrees in abduction, and 69 to 84 degrees in external rotation. There was no difference in patient satisfaction regarding the final outcome between the conventional prepectoral reconstruction group and the study group. Conclusion Shoulder exercises in irradiated patients who underwent subpectoral reconstruction were improved by delayed prepectoral conversion using an ADM inlay graft. It is recommended that subpectoral reconstruction not be ruled out due to concerns regarding muscle contracture and shoulder morbidity in radiation-planned patients with poor mastectomy skin flaps.
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Affiliation(s)
- Jin Sol Park
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Escandón JM, Weiss A, Christiano JG, Langstein HN, Escandón L, Prieto PA, Gooch JC, Manrique OJ. Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:411. [PMID: 38213807 PMCID: PMC10777228 DOI: 10.21037/atm-23-1094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/02/2023] [Indexed: 01/13/2024]
Abstract
Background and Objective With the incorporation of autologous fat grafting, acellular dermal matrix (ADM) products, and nipple-sparing mastectomy, prepectoral device placement has become more popular in selected patients when compared to partial submuscular (dual plane) or complete submuscular device placement. In this article, we aimed to present a review of the current state-of-the-art for implant-based breast reconstruction (IBBR) using expanders. Additionally, we present a case series of our experience with IBBR evaluating perioperative outcomes, complications, and patient-reported outcomes (PRO). Methods For our series, we retrospectively evaluated adult female patients undergoing 2-stage immediate IBBR after total mastectomy between 2011 and 2021. We performed a systematic search across PubMed MEDLINE for articles evaluating outcomes of prepectoral versus subpectoral two-stage IBBR with expanders published from database inception through February 28th, 2023. Key Content and Findings Both prepectoral and subpectoral are safe alternatives for two-stage IBBR. Due to current advancements in the field of breast reconstruction, prepectoral IBBR has gained popularity and has a comparable rate of complications compared to a subpectoral approach in selected patients according to high-quality articles. In patients with several comorbidities, current tobacco use, history of preoperative radiation, and limited perfusion of the mastectomy flaps, subpectoral device placement should be given special consideration as a layer of vascularized tissue can decrease the risk of major complications or unplanned procedures. As prepectoral device placement does not require dissection of the pectoral muscles, faster recovery, better implant position, decreased pain, and a shorter time to complete expansion is expected. The plane of reconstruction does not seem to significantly affect the time for expander-to-implant exchange or PRO for quality-of-life (QOL) according to most studies. Conclusions Prepectoral and subpectoral IBBR demonstrated a comparable rate of complications in selected patients. Nonetheless, perioperative outcomes seem to be improved using a prepectoral approach in terms of reduced pain, reduced time to conclude outpatient expansions, and less animation deformity.
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Affiliation(s)
- Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Jose G. Christiano
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard N. Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Lauren Escandón
- School of Medicine, Universidad El Bosque, Bogotá DC, Colombia
| | - Peter A. Prieto
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Jessica C. Gooch
- Division of Surgical Oncology, Department of Surgery, Pluta Cancer Center, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Clausen-Oreamuno C, Perez-Rodrigo S, Stillaert FBJL, Tejerina A, Tejerina A, Shellock FG. Benefits of Using Magnetic Resonance Imaging During Breast Tissue Expansion: Literature Review and Case Series. Aesthet Surg J 2023; 44:50-59. [PMID: 37577837 DOI: 10.1093/asj/sjad264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023] Open
Abstract
Breast cancer results in up to 1.6 million new candidates for yearly breast reconstruction (BR) surgery. Two-stage breast reconstruction surgery with the use of a tissue expander (TE) is a common approach to reconstructing the breast after mastectomy. However, a common disadvantage encountered with the traditional breast TE is the magnetic injection port, which has been reported to cause injuries in patients undergoing magnetic resonance (MR) imaging. Therefore this type of breast TE is labeled "MR unsafe." Recent technological advances have incorporated radio-frequency identification (RFID) technology in the TE to allow for the location of the injection port without magnetic components, resulting in an MR-conditional TE. This paper aims to review the information regarding the safety profile of TEs with magnetic ports and to gather distinct clinical scenarios in which an MR-conditional TE benefits the patient during the BR process. A literature review ranging from 2018 to 2022 was performed with the search terms: "tissue expander" OR "breast tissue expander" AND "magnetic resonance imaging" OR "MRI." Additionally, a case series was collected from each of the authors' practices. The literature search yielded 13 recent peer-reviewed papers, and 6 distinct clinical scenarios were compiled and discussed. Most clinicians find MRI examinations to be the state-of-art diagnostic imaging modality. However, due to the preexisting risks associated with TEs with magnetic ports, the MRI labeling classification should be considered when deciding which TE is the most appropriate for the patient requiring MRI examinations. LEVEL OF EVIDENCE: 4
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7
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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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Martins LL, Barbosa RF, Guerreiro FC, Andresen C, Pereira MJ, Pinho CJ, Rebelo MA, Ribeiro MM. A Two-Year Retrospective Analysis of the Clinical Outcomes of Immediate Submuscular Breast Reconstructions With Native® Acellular Dermal Matrix. Cureus 2023; 15:e41343. [PMID: 37546031 PMCID: PMC10399605 DOI: 10.7759/cureus.41343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Implant-based submuscular breast reconstruction (SBR) can be performed with the aid of acellular dermal matrices (ADM) for implant coverage on their inferolateral pole, aiming at providing a biological interface for hiding the implant and therefore reducing the risk of complications. The purpose of this study is to assess the long-term post-operative outcomes obtained using the SBR-specific Native® ADM (DECO med s.r.l., Marcon, Venice, Italy). METHODS All cases of Native®-assisted immediate SBR performed at our institution between October 2016 and March 2020 were retrospectively analysed. Demographic and surgical data were collected, and post-operative outcomes, including minor and major complications, were evaluated. Particular attention was paid to complications emerging before and after patient discharge. Dependence analyses were performed to uncover statistically significant relationships between risk factors and reconstructive outcomes. RESULTS Data on 100 patients were collected, for a total of 128 breasts. The mean age of the cohort was 49.5 years, the mean BMI was 23.4 kg/m2, and the mean follow-up was 24 months. Out of this, 14.1% of patients received pre-operative radiotherapy, while 16.4% underwent post-mastectomy radiotherapy. Breasts appeared to develop short-term minor complications more likely during hospitalisation (11.7% vs. 7.8%), while short-term major complications occurred more often after discharge (7.8% vs. 15.6%). The most frequent long-term complications were capsular contracture and contour defects (both 9.4%). Risk factors that showed a statistically significant relationship with complications were pre- and post-mastectomy radiotherapy and post-operative chemotherapy. CONCLUSIONS The retrospective analysis showed results in line with clinical outcomes reported in the literature for the same reconstructive technique. The use of Native® ADM in SBR is safe and effective in the long term.
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Affiliation(s)
- Larissa L Martins
- Department of Plastic, Reconstructive, Craniomaxillofacial and Hand Surgery and Microsurgery Unit, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
- Department of Plastic Surgery, Hospital da Prelada, Porto, PRT
| | - Rui F Barbosa
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia do Porto Francisco Gentil, EPE, Porto, PRT
| | - Frederico C Guerreiro
- Department of Reconstructive and Maxillofacial Plastic Surgery, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - Carolina Andresen
- Department of Plastic, Reconstructive, Craniomaxillofacial and Hand Surgery and Microsurgery Unit, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Miguel J Pereira
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia do Porto Francisco Gentil, EPE, Porto, PRT
| | - Carlos J Pinho
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia do Porto Francisco Gentil, EPE, Porto, PRT
| | - Marco A Rebelo
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia do Porto Francisco Gentil, EPE, Porto, PRT
| | - Matilde M Ribeiro
- Department of Plastic and Reconstructive Surgery, Instituto Português de Oncologia do Porto Francisco Gentil, EPE, Porto, PRT
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Cammarata E, Toia F, Rossi M, Cipolla C, Vieni S, Speciale A, Cordova A. Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study. Healthcare (Basel) 2023; 11:1741. [PMID: 37372859 DOI: 10.3390/healthcare11121741] [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: 04/08/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.
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Affiliation(s)
- Emanuele Cammarata
- Plastic and Reconstructive Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Francesca Toia
- Plastic and Reconstructive Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Matteo Rossi
- Plastic and Reconstructive Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Calogero Cipolla
- Oncological Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Salvatore Vieni
- Oncological Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Antonino Speciale
- Plastic and Reconstructive Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Adriana Cordova
- Plastic and Reconstructive Surgery Unit, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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10
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Perez K, Rodnoi P, Teotia SS, Haddock NT. A Propensity Score-Matched Comparison of Perioperative Outcomes in Prepectoral Smooth Versus Textured Tissue Expander Breast Reconstruction. Ann Plast Surg 2023; 90:S242-S251. [PMID: 37227405 DOI: 10.1097/sap.0000000000003397] [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: 05/26/2023]
Abstract
INTRODUCTION Textured tissue expanders (TEs) had previously gained popularity due to minimizing expander migration, rotation, and capsule migration. Recent studies, though, have revealed increased risk of anaplastic large-cell lymphoma associated with certain macrotextured implants, prompting surgeons at our institution to switch to smooth TEs; evaluation is thus required for specific viability and similarity of outcomes of smooth TEs. Our study aims to evaluate perioperative complications in prepectoral placement of smooth versus textured TEs. METHODS Our retrospective study evaluated perioperative outcomes of patients who underwent bilateral prepectoral TE placement, with either smooth or textured TE, at an academic institution between 2017 and 2021 performed by 2 reconstructive surgeons. The perioperative period was defined as the interval between expander placement until conversion to flap/implant or removal of TE due to complications. Our primary outcomes included hematoma, seroma, wounds, infection, unspecified redness, total number of complications, and returns to operating room secondary to complications. Secondary outcomes included time to drain removal, total number of expansions, hospital length of stay, length of time until the next breast reconstruction procedure, next breast reconstruction procedure, and number of expansions. RESULTS Two hundred twenty-two patients were evaluated in our study (141 textured, 81 smooth). After propensity matching (71 textured, 71 smooth), our univariate logistic regression showed no significant difference in perioperative complications between smooth and textured expanders (17.1% vs 21.1%; P = 0.396) or complications that required a return to the operating room (10.0% vs 9.2%; P = 0.809). No significant differences were noted for hematoma, seroma, infections, unspecified redness, or wounds between both groups. A significant difference was noted in days to drain out (18.57 ± 8.17 vs 20.13 ± 0.07, P = 0.001) and type of the next breast reconstruction procedure (P < 0.001). Our multivariate regression showed that breast surgeon, hypertension, smoking status, and mastectomy weight were significant for increased risk for complications. CONCLUSION Our study demonstrates similar rates and effectiveness of smooth versus textured TE when used for prepectoral placement, making smooth TEs a safe and valuable alternative for breast reconstruction because of their decreased risk of anaplastic large-cell lymphoma compared with textured TEs.
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Affiliation(s)
- Kevin Perez
- From the Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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Pagliara D, Schiavone L, Garganese G, Bove S, Montella RA, Costantini M, Rinaldi PM, Bottosso S, Grieco F, Rubino C, Salgarello M, Ribuffo D. Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques. Clin Breast Cancer 2023; 23:249-254. [PMID: 36725477 DOI: 10.1016/j.clbc.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/31/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023]
Abstract
Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons' clinical experience. Even though numerous studies have already addressed the patients' risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.
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Affiliation(s)
- Domenico Pagliara
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy.
| | - Laurenza Schiavone
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Roma, Italy
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Rino Aldo Montella
- Radiology Unit, Mater Olbia Hospital, Mater Olbia Hospital, Olbia, Italy
| | - Melania Costantini
- Radiology Unit, Mater Olbia Hospital, Mater Olbia Hospital, Olbia, Italy
| | | | - Stefano Bottosso
- Department of Medical, Surgical and Health Sciences, Plastic Surgery Unit, University of Trieste, Ospedale di Cattinara, ASUGI, Trieste, Italy
| | - Federica Grieco
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari University Hospital Trust, Sassari, Italy
| | - Corrado Rubino
- Department of Medical, Surgical and Experimental Sciences, Plastic Surgery Unit, University of Sassari, Sassari University Hospital Trust, Sassari, Italy
| | - Marzia Salgarello
- Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Diego Ribuffo
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Roma, Italy
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Cogliandro A, Salzillo R, De Bernardis R, Loria FS, Petrucci V, Barone M, Tenna S, Cagli B, Persichetti P. Prepectoral Versus Subpectoral Direct-to-Implant Breast Reconstruction: Evaluation of Patient's Quality of Life and Satisfaction with BREAST-Q. Aesthetic Plast Surg 2023:10.1007/s00266-023-03316-z. [PMID: 36944866 DOI: 10.1007/s00266-023-03316-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/26/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Over the years, plastic surgery has acquired a central role in the integrated treatment of breast cancer. Direct-to-implant (DTI) reconstruction using the prepectoral approach has emerged as an alternative to reconstruction using the subpectoral technique to overcome the complications arising from this type of surgery resulting as a consequence of muscle elevation. The satisfaction and quality of life of patients undergoing DTI breast reconstruction were evaluated using the BREAST-Q questionnaire, comparing the prepectoral and the subpectoral technique. METHODS A single-center cross-sectional study on patients who underwent mastectomy and DTI breast reconstruction at our institution between 2013 and 2021 was conducted. Eighty-one patients were included and mainly divided into two groups based on the surgical procedure: 52 patients undergoing a subpectoral breast reconstruction approach and 29 patients receiving a prepectoral breast reconstruction. In order to assess the quality of life, the postoperative BREAST-Q module was administered electronically to the enrolled patients. RESULTS Higher scores in BREAST-Q domains were recorded from patients who underwent mastectomy and breast reconstruction with prepectoral technique: psychosocial well-being (P<0.0085), sexual well-being (P<0.0120), physical well-being: lymphoedema (P<0.0001) and satisfaction with information received (P<0.0045). There were further statistically significant differences between the two groups with regard to postoperative complications (p<0.0465) and the need for reoperation (p<0.0275). CONCLUSIONS Patients who underwent DTI breast reconstruction with prepectoral technique were more satisfied in terms of psychosocial, sexual and also physical well-being. These patients also had statistically lower complications and reoperations compared to patients who received breast reconstruction with the subpectoral technique. LEVEL OF EVIDENCE IV This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Annalisa Cogliandro
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy.
| | - Rosa Salzillo
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Riccardo De Bernardis
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Francesco Saverio Loria
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Valeria Petrucci
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Mauro Barone
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
- Research group "To be and to appear: Objective indication to Plastic Surgery" of Campus Bio-Medico University in Rome, Rome, Italy
| | - Stefania Tenna
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Barbara Cagli
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
| | - Paolo Persichetti
- Fondazione Policlinico Universitario, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy
- Research group "To be and to appear: Objective indication to Plastic Surgery" of Campus Bio-Medico University in Rome, Rome, Italy
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13
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Optimizing Prepectoral Implant Placement and Concomitant Fat Grafting After Tissue Expansion. Ann Plast Surg 2023:00000637-990000000-00218. [PMID: 36921323 DOI: 10.1097/sap.0000000000003446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
BACKGROUND Prepectoral implant-based breast reconstruction is often supplemented by autologous fat grafting to optimize aesthetic outcomes. This usually entails several rounds of modest fat transfer to minimize risk of necrosis; however, the limits of fat grafting at expander exchange are not known. METHODS A single-institution retrospective review from July 2016 to February 2022 was performed of all patients who underwent (1) mastectomy, (2) prepectoral tissue expander placement, (3) expander exchange for implant, and (4) at least one round of autologous fat transfer. Student t test and χ2 test were used. RESULTS A total of 82 breasts underwent a single round of fat grafting during implant placement (group 1); 75 breasts underwent fat grafting that occurred in multiple rounds and/or in delay to implant placement (group 2). Group 1 received more fat at the time of implant placement (100 mL; interquartile range, 55-140 mL; P < 0.001) and underwent fewer planned operative procedures compared with group 2 (1.0 vs 2.2, P < 0.001). Total fat volume in group 2 did not significantly exceed that of group 1 until after 3 rounds of fat transfer (128.5 mL; interquartile range, 90-130 mL; P < 0.01). There was no difference in the rate of fat necrosis between groups after the first round (15.9% vs 9.3%, P = 0.2) and final round (15.9% vs 12.0%, P = 0.5) of fat grafting. Complication rates were similar between groups (3.7% vs 8.0%, P = 0.2). CONCLUSIONS A 2-stage approach of prepectoral tissue expander placement with single round of larger volume fat transfer at expander exchange reduces overall number of operative procedures without increased risks.
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Yan C, Zhang J, Liu Z. Breast reconstruction with combined large omentum and prosthesis after breast cancer surgery: A case report. Asian J Surg 2023:S1015-9584(23)00144-6. [PMID: 36759314 DOI: 10.1016/j.asjsur.2023.01.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Chaozhen Yan
- Department of Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingyang Zhang
- Department of Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenzhen Liu
- Department of Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China.
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15
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Xie J, Wang M, Cao Y, Zhu Z, Ruan S, Ou M, Yu P, Shi J. ADM-assisted prepectoral breast reconstruction is not associated with high complication rate as before: a Meta-analysis. J Plast Surg Hand Surg 2023; 57:7-15. [PMID: 34581645 DOI: 10.1080/2000656x.2021.1981351] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Implant-related breast reconstruction can be divided into subpectoral breast reconstruction (SPBR) and prepectoral breast reconstruction (PPBR) according to the different anatomical planes. The previous stereotype was that PPBR had a high complication rate and was not suitable for clinical use. However, with the emergence of acellular dermal matrix (ADM), the clinical effect of PPBR has been improved. To compare the outcomes difference between SPBR and PPBR, We conducted this meta-analysis. Articles on SPBR versus PPBR were searched in PubMed, Web of Sciences, Embase, and Cochrane databases, strictly following the PRISMA guidelines. According to the set criteria, we included the literature that met the requirements. Extracted data were the incidence of adverse events and the duration of drainage. Results show that SPBR has a higher incidence rate in capsular contracture, animation deformity, infection, hematoma and delayed healing wound than PPBR. There are no significant differences in skin flap necrosis, seroma, implant loss, reoperation and duration of drainage between the two groups. Hence, PPBR is no longer a high complication surgical method and can be used in the clinical practice. However, there are few large sample studies at present, so it is necessary to carry out further studies on PPBR.
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Affiliation(s)
- Jiaheng Xie
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ming Wang
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuan Cao
- Fourth School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhechen Zhu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shujie Ruan
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mengmeng Ou
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Pan Yu
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jingping Shi
- Department of Burn and Plastic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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16
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Zheng C, Liu J, Wen Y, Lin S, Han H, Xu C. A systematic review and meta-analysis of postmastectomy radiation therapy on prepectoral versus subpectoral breast reconstruction. Front Surg 2023; 9:1019950. [PMID: 36700017 PMCID: PMC9869385 DOI: 10.3389/fsurg.2022.1019950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/02/2022] [Indexed: 01/11/2023] Open
Abstract
Background Prepectoral breast reconstruction has once again appealed, which attributes to the introduction of acellular dermal matrices (ADMs) and mesh. Postmastectomy radiation therapy (PMRT), meanwhile, is crucial in the whole course of treatment for breast cancer patients with lymph node-positive. The impact of PMRT on outcomes after prepectoral breast reconstruction has not been clearly defined to date. This study aimed to compare the impact of PMRT on outcomes after prepectoral vs. subpectoral breast reconstruction. Methods A comprehensive research on databases including PubMed, Embase, and Cochrane libraries was performed to retrieve literature pertaining to prepectoral breast reconstruction from database inception to October 2021. All included studies evaluated the impact of PMRT on outcomes after breast reconstruction. Only studies comparing patients who underwent prepectoral breast reconstruction with a control group who underwent subpectoral breast reconstruction were included. Data were analyzed using RevMan version 5.2. Results A total of 4 studies were included in the meta-analysis, with a total of 394 breasts. In the setting of postmastectomy radiation therapy, 164 breasts were reconstructed with a prepectoral approach, whereas the remaining 230 breasts underwent subpectoral reconstruction. Overall, outcomes between PBR and SBR was no statistical significance in the overall complications (OR: 1.30, 95% CI: 0.35-4.85), infection (OR: 1.62, 95% CI: 0.90-2.91), seroma (OR: 1.60, 95% CI: 0.48-5.27), skin flap necrosis (OR: 0.77, 95% CI: 0.17-3.45), hematoma (OR: 0.38, 95% CI: 0.10-1.41), wound dehiscence (OR: 0.82, 95% CI: 0.36-1.85). But, included studies lacked data about the patient quality of life and satisfaction with the outcome of the reconstructed breast. Conclusions In the setting of postmastectomy radiation therapy, prepectoral breast reconstruction is a safe and effective option.
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Affiliation(s)
- Caihong Zheng
- The Graduate School of Fujian Medical University, Fuzhou, China,Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jiameng Liu
- Department of Breast Surgery, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yahui Wen
- The Graduate School of Fujian Medical University, Fuzhou, China,Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shunguo Lin
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Breast Cancer Institute, Fujian Medical University, Fuzhou, China
| | - Hui Han
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Breast Cancer Institute, Fujian Medical University, Fuzhou, China
| | - Chunsen Xu
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Breast Cancer Institute, Fujian Medical University, Fuzhou, China,Correspondence: Chunsen Xu
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17
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A Comparative Study of Secondary Procedures after Subpectoral and Prepectoral Single-Stage Implant-Based Breast Reconstruction. Plast Reconstr Surg 2023; 151:7-15. [PMID: 36194056 DOI: 10.1097/prs.0000000000009745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Implant-based breast reconstruction (IBR) is the most commonly used procedure to reconstruct the breast after mastectomy. The advantages and disadvantages of subpectoral versus prepectoral implant placement remain a matter of debate. This study compares the need for secondary aesthetic procedures between prepectoral and subpectoral IBR. METHODS This is a retrospective cohort study of consecutive patients who underwent subpectoral or prepectoral IBR between 2015 and 2018 under a single surgeon at a tertiary breast unit. The primary endpoint was the number of secondary procedures performed to improve the aesthetic outcome. Secondary endpoints included the number of secondary procedures during the first year. RESULTS A total of 271 one-stage IBRs were performed (subpectoral, n = 128 in 74 patients; prepectoral, n = 143 in 84 patients). Overall, more patients required secondary procedures in the subpectoral group (36.5% versus 19%; P = 0.014), although through longer follow-up. The most common procedures were pocket revision and implant exchange [11.7% versus 3.5% ( P = 0.010); 11.7% versus 4.2% ( P = 0.021)], whereas fat grafting was similar between the two groups (46% versus 40.5%; P = 0.777). When adjusted for follow-up time, there was no significant difference in the number of secondary procedures undertaken in the subpectoral versus the prepectoral group (21% versus 16%, respectively; P = 0.288) at 1 year. CONCLUSIONS The requirement for secondary procedures at 1 year was not different between groups. The need for fat grafting was not increased following prepectoral IBR. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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18
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Baychorov EA, Zikiryakhodzhaev AD, Ismagilov AK, Przhedetskiy YV. The influence of synthetic and biologic matrices on the choice of the implant plane during breast reconstruction. The modern state of the problem. TUMORS OF FEMALE REPRODUCTIVE SYSTEM 2022. [DOI: 10.17650/1994-4098-2022-18-3-64-70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Immediately after silicone implants were described, the technique of prepectoral implant placement dominated in breast reconstructive surgery. However, this plane soon had to be abandoned due to the high frequency of complications, such as infection, capsular contracture, explantation. For these reasons, surgeons soon had to switch to the subpectoral plane. Several decades later, thanks to the discovery of synthetic and biological meshes, surgeons returned to the prepectoral plane, but at a technically new level.The purpose of this review was to analyze the role of biological and synthetic matrices as factors influencing the choice of the implant plane in one-stage breast reconstruction.
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Affiliation(s)
| | - A. D. Zikiryakhodzhaev
- P. Hertsen Moscow Oncology Research Institute – branch of the National Medical Research Radiological Centre of the Ministry of Health of Russia; I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia
| | - A. Kh. Ismagilov
- Kazan State Medical Academy – branch of Federal State Budgetary Educational Institution of Higher Professional Education of Russian Medical Academy of Postgraduate Education of Ministry of Health of Russia; Republican Clinical Сancer Center named after prof. M. Z. Sigal
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19
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Dai L, Cui H, Bao Y, Hu L, Zhou Z, Wang M, Lin S, Wu H, Kang H, Ma X. The relationship between immediate postmastectomy reconstruction modalities and survival benefits in patients with triple negative breast cancer. Cancer Med 2022; 12:2782-2794. [PMID: 36106621 PMCID: PMC9939230 DOI: 10.1002/cam4.5166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 08/02/2022] [Accepted: 08/12/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Immediate postmastectomy reconstruction for breast cancer has been widely used due to its unique esthetic and psychological effects. However, no other population-based study has investigated the effects of different reconstruction types on the survival in patients with triple negative breast cancer (TNBC). METHODS We selected patients who met the eligibility criteria from the Surveillance, Epidemiology, and End Results cancer registry (N = 9760). We then assessed the effect of different reconstructive surgical approaches (implant, autologous, implant and autologous combined reconstruction) on the overall survival (OS) and breast cancer-specific survival (BCSS) by using the Kaplan-Meier survival curve and Cox proportional hazard regression analyses. The nomograms were used to predict OS and BCSS. And the competitive risk model was used to assess breast cancer-specific death (BCSD) and non-breast cancer-specific death (NBCSD). RESULTS Statistical analysis suggested that the three reconstruction methods had better OS and BCSS with lower hazard than mastectomy alone (log-rank test, p < 0.05). Multivariate stratified analysis showed that patients aged 40-60 years had the greatest improvement in OS (Adjusted hazard ratio [AHR], 0.646; 95% Confidence Interval [CI], 0.439-0.950; p = 0.026) with combined reconstruction. BCSS could be improved only by implant reconstruction (AHR, 0.672; 95% CI, 0.514-0.878; p = 0.004). In addition, autologous reconstruction (AHR, 0.570; 95% CI, 0.350-0.929; p = 0.024) and implant reconstruction (AHR, 0.538; 95% CI, 0.339-0.853; p = 0.008) improved OS in patients >60 years of age. The survival prediction model quantified the survival benefits of TNBC patients undergoing different surgeries. Moreover, the C-indexes showed the good predictive ability of the nomograms. CONCLUSIONS Our results suggest that for TNBC patients, there is a survival benefit of immediate postmastectomy reconstruction compared with mastectomy alone. Among them, implant reconstruction has the most obvious advantage.
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Affiliation(s)
- Luyao Dai
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Hanxiao Cui
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Yuanhang Bao
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Liqun Hu
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Zhangjian Zhou
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Meng Wang
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Shuai Lin
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Hao Wu
- School of Basic Medical Sciences, Xi'an Key Laboratory of Immune Related DiseasesXi'an Jiaotong UniversityXi'anShaanxiChina
| | - Huafeng Kang
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
| | - Xiaobin Ma
- Department of OncologyThe Second Affiliated Hospital of Xi'an Jiaotong UniversityXi'anShaanxiChina
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20
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Wang ML, Qin N, Valenti AB, Huang H, Otterburn DM. Twenty-Hour–Hour Peri-Operative Antibiotic Prophylaxis in Tissue Expander Reconstruction: Our Ten-Year Institutional Experience. Surg Infect (Larchmt) 2022; 23:740-746. [DOI: 10.1089/sur.2022.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marcos Lu Wang
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Nancy Qin
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Alyssa B. Valenti
- NewYork-Presbyterian Hospital–Cornell and Columbia, New York, New York, USA
| | - Hao Huang
- NewYork-Presbyterian Hospital–Cornell and Columbia, New York, New York, USA
| | - David M. Otterburn
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York, USA
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21
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Klinger F, Lisa A, Testori A, Vaccari S, Bandi V, Lorenzano V, Klinger M, Tinterri C, Vinci V. Immediate direct-to-implant breast reconstruction: A single center comparison between different procedures. Front Surg 2022; 9:935410. [PMID: 35923444 PMCID: PMC9339688 DOI: 10.3389/fsurg.2022.935410] [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: 05/03/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe increased incidence of conservative mastectomy operations (nipple- and skin- sparing) has increased the frequency of immediate breast reconstructions (IBR). In order to guarantee patients the best possible aesthetic outcome, the least chance of complications and moreover, the least postoperative pain, the technique with prepectoral prosthetic pocket was recently reconsidered with the use of ADM. This is the first study using Fortiva® in prepectoral breast reconstruction, and it compares the outcomes of three different patient populations (undergoing retromuscular, prepectoral and prepectoral reconstruction with ADM). The authors suggest that prepectoral breast reconstruction with ADM may bring benefits compared to the current standard technique (retromuscular) as well as compared to the prepectoral reconstruction without ADM.MethodsRetrospective data analysis of patients who underwent mastectomy followed by immediate breast reconstruction with silicone implants (DTI), performed by a team of breast surgeons and plastic surgeons. Logistic factor regressions were performed in order to investigate the effects of the three different intervention techniques on the incidence of complications. Fisher's exact test was used to analyze the differences in the occurrence of each complication. Mann Whitney test was used to compare the averages of referred pain. A p value <0.05 was considered significant.ResultsA total of 67 patients underwent DTI reconstruction, of which 43 with retromuscular prosthesis, 13 prepectoral and 11 prepectoral with ADM. We found a significantly lower incidence of surgical complications with ADM, exclusively in comparison with retromuscular reconstruction (p = 0.028). It emerges prepectoral reconstruction with ADM involves significantly less visibility of the implant than both the prepectoral surgery without ADM (p = 0.013) and the retromuscular technique (p = 0.029). Finally, postoperative pain referred at twelfth month is significantly less relevant in the group with prepectoral prosthesis and ADM, both in the group with retromuscular (p < 0.001) and prepectoral without ADM (p = 0.001).ConclusionsThis study demonstrates that immediate prepectoral breast reconstruction with ADM is a safe and reliable technique, able to exceed some type of limits imposed by prepectoral reconstruction. Moreover, it provides benefits if compared to the current standard technique. In the future, this technique could also be added to it, after a proper selection of patients in pre- and intraoperative time.
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Affiliation(s)
- Francesco Klinger
- Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Milan, Italy
| | - Andrea Lisa
- Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Milan, Italy
| | - Alberto Testori
- Thoracic Surgery Department, Humanitas Research Hospital and Cancer Center, Milan, Italy
| | - Stefano Vaccari
- Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Milan, Italy
| | - Valeria Bandi
- Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Milan, Italy
| | - Valerio Lorenzano
- Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Milan, Italy
| | - Marco Klinger
- Department of Medical Biotechnology and Translational Medicine BIOMETRA, Plastic Surgery Unit, BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Milan, Italy
| | - Corrado Tinterri
- Breast Surgery Department, Humanitas Research Hospital, Milan, Italy
| | - Valeriano Vinci
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Humanitas Clinical and Research Center-IRCCS, Milan, Italy
- Correspondence: Valeriano Vinci
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Dawson SE, Berns JM, Tran PC, Fisher CS, Ludwig KK, Lester ME, Hassanein AH. Optimizing tissue expander breast reconstruction in nicotine users: An algorithmic approach. J Plast Reconstr Aesthet Surg 2022; 75:3628-3651. [PMID: 35842287 DOI: 10.1016/j.bjps.2022.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Smoking is a risk factor for post-operative complications following breast reconstruction. Abruptly refraining from all nicotine products may be difficult for patients with a new cancer diagnosis. The goal of this study is to assess complications following a distinct approach to tissue expander reconstruction in nicotine users. METHODS Patients who underwent tissue expander reconstruction after mastectomy were retrospectively reviewed. The approach to optimize outcomes in smokers was to delay reconstruction at least 7 days after the mastectomy and place the expander submuscularly (Group I). The other patients underwent standard immediate reconstruction on the day of mastectomy and were divided into Group II (active smokers) and Group III (non-smokers). Group III was considered the control group. RESULTS There was a total of 195 patients (323 breast reconstructions): Group I (10 patients, 19 expanders); Group II (11 patients, 19 expanders) and Group III (174 patients, 285 expanders). In Group I, n = 1/19 breasts had wound dehiscence requiring surgical management, compared to n = 18/285 in Group III (p = 1.0). Group II exhibited more wound dehiscence (n = 6/19) compared to Group III (p = 0.002). There was no significant difference when comparing wound dehiscence in prepectoral expander placement (7.0%) versus submuscular placement (4.8%) in Group III (p = 0.60). CONCLUSION Nicotine users who are offered tissue expander breast reconstruction 1) at least 7 days after the mastectomy (to allow for vascular delay and demarcation) and 2) in the submuscular plane can normalize their risk of skin necrosis to that of non-smokers who have standard (prepectoral or submuscular) reconstruction on the day of mastectomy.
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Affiliation(s)
- Steven E Dawson
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202, United States.
| | - Jessica M Berns
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202, United States
| | - Phu C Tran
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202, United States
| | - Carla S Fisher
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, United States
| | - Kandice K Ludwig
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, United States
| | - Mary E Lester
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202, United States
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202, United States.
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Maruccia M, Elia R, Tedeschi P, Gurrado A, Moschetta M, Testini M, Giudice G. Prepectoral breast reconstruction: an ideal approach to bilateral risk-reducing mastectomy. Gland Surg 2021; 10:2997-3006. [PMID: 34804886 DOI: 10.21037/gs-21-339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022]
Abstract
Background Bilateral risk-reducing mastectomy (BRRM) has increased its popularity in the last years because of its aim to minimise the chances of developing breast cancer in high-risk patients. Women undergoing this procedure must be considered highly demanding patients given the need to combine aesthetical, functional and preventive desires. This study aims to present the authors' experience in performing BRRM followed by single-stage prepectoral reconstruction (PPBR) with implant completely covered by acellular dermal matrix (ADM) and to report indications, surgical techniques, functional and aesthetic results. Methods A single-centre prospective data collection was carried out from January 2017 to January 2021 of patients at high risk of developing breast cancer undergoing BRRM and immediate PPBR with ADM. Patients were subdivided into two groups according to the breast shape: Group A had small and medium size breasts and Group B had large and ptotic breasts. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through the BREAST-Q questionnaire. Results A total of twenty-three patients met the inclusion criteria. Seventeen patients were included in group A and six patients in group B. Average follow-up was 18.4 months. Minor complications occurred in four breasts: one seroma, one hematoma and two cases of wound dehiscence. Capsular contracture was not observed. All patients were satisfied with the final result according to the post-operative BREAST-Q questionnaire. Conclusions Immediate prepectoral breast reconstruction could represent the ideal reconstruction option after BRRM and should be offered to all women that fulfil the inclusion criteria.
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Affiliation(s)
- Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
| | - Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
| | - Pasquale Tedeschi
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
| | - Angela Gurrado
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
| | - Marco Moschetta
- Interdisciplinary Department of Medicine, Section of Diagnostic Imaging, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Piazza Giulio Cesare, Bari, Italy
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A Comparison of BREAST-Q Scores between Prepectoral and Subpectoral Direct-to-Implant Breast Reconstruction. Plast Reconstr Surg 2021; 148:708e-714e. [PMID: 34705769 DOI: 10.1097/prs.0000000000008410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subpectoral breast implant placement has in recent history predominated in breast reconstruction, but there has been more recent adoption of prepectoral implant reconstruction. There has been limited study to date of patient-reported outcomes comparing the two techniques. METHODS Patients who underwent direct-to-implant breast reconstruction between 2013 and 2018 were included in this retrospective cohort study. Eligible patients were asked to complete BREAST-Q domains comparing quality of life and satisfaction. Descriptive, t test, chi-square test, and multivariate linear regression analyses were performed to compare BREAST-Q scores. Significance was defined as p ≤ 0.05. RESULTS There were 64 patients (114 breasts) who underwent prepectoral reconstruction and 37 patients (68 breasts) who underwent subpectoral reconstruction. Among the 101 women (182 breasts), there were no significant differences between BREAST-Q scores and implant position for the Satisfaction with Breasts domain (adjusted p = 0.819), Psychosocial Well-being domain (adjusted p = 0.206), or Physical Well-being Chest domain (adjusted p = 0.110). The subpectoral implant cohort was associated with higher scores, 53 versus 47, for the Sexual Well-being module (adjusted p = 0.001). CONCLUSIONS Patients undergoing direct-to-implant breast reconstruction had comparable BREAST-Q satisfaction scores for most modules regardless of implant plane. The subpectoral implant cohort scored higher for sexual well-being.
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Do We Need Support in Prepectoral Breast Reconstruction? Comparing Outcomes with and without ADM. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3745. [PMID: 34386310 PMCID: PMC8354628 DOI: 10.1097/gox.0000000000003745] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/08/2021] [Indexed: 11/27/2022]
Abstract
Background: The majority of two-stage prepectoral breast reconstruction has been described utilizing acellular dermal matrix (ADM). Although reports of prepectoral breast reconstruction without ADM exist, there is a paucity of comparative studies. Methods: A single-institution retrospective review was performed of consecutive patients undergoing immediate prepectoral two-stage breast reconstruction with tissue expanders from 2017 to 2019. Short-term reconstructive and aesthetic complications were compared between cases that utilized ADM for support and those that did not. Results: In total, 76 cases (51 patients) were identified, of which 35 cases utilized ADM and 41 did not. Risk factors and demographics were similar between the two cohorts with the exception of body mass index, which was higher in the ADM cohort (29.3 versus 25.4, P = 0.011). Average follow-up length was also longer in patients who received ADM (20.3 versus 12.3 months, P < 0.001). Intraoperative expander fill was higher in patients who did not receive ADM (296.8 cm3 versus 151.4 cm3, P < 0.001) though final implant size was comparable in both cohorts (P = 0.584). There was no significant difference in the rate of any complication between the ADM and no ADM cohorts (25.7% versus 17.1%, respectively P = 0.357), including major mastectomy flap necrosis (P = 0.245), major infection (P = 1.000), seroma (P = 0.620), expander explantation (P = 1.000), capsular contracture (P = 1.000), implant dystopia (P = 1.000), and rippling (P = 0.362). Conclusions: Immediate two-stage prepectoral breast reconstruction with tissue expanders has comparable rates of short-term complications with or without ADM support. Safety of prepectoral expander placement without ADM may warrant more selective ADM use in these cases.
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Splitting the Difference: Using Synthetic and Biologic Mesh to Decrease Cost in Prepectoral Immediate Implant Breast Reconstruction. Plast Reconstr Surg 2021; 147:580-584. [PMID: 33620924 DOI: 10.1097/prs.0000000000007638] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
SUMMARY Prepectoral breast reconstruction has minimized morbidity and dynamic deformities associated with submuscular implant-based breast reconstruction. However, reliance on implant coverage with acellular dermal matrix in immediate implant reconstruction remains limited by high material costs. The authors describe a technique in which anterior implant coverage in prepectoral reconstruction is split into acellular dermal matrix inferolaterally and synthetic, absorbable mesh superiorly. Use of acellular dermal matrix inferiorly provides coverage and reinforces the inframammary fold, whereas the absorbable mesh is trimmed and sutured to the acellular dermal matrix at the appropriate tension to support the implant and relieve pressure on mastectomy flaps. A retrospective review was performed on all consecutive prepectoral one-stage breast reconstructions using this technique at a single institution. Patient demographics, mastectomy and reconstruction characteristics, reconstructive outcomes, and cost of support materials were queried and analyzed. Eleven patients (21 breasts) underwent prepectoral immediate implant reconstruction with Vicryl and acellular dermal matrix anterior coverage. Average mastectomy weight was 775.8 g. Smooth, round cohesive implants were used in all cases and average implant size was 514.5 ml. Overall complication rates were low and included one minor infection (4.8 percent) and one case of minor mastectomy flap and partial nipple necrosis each (4.8 percent). Calculated cost savings of Vicryl and acellular dermal matrix anterior coverage was up to $3415 in unilateral and $6830 in bilateral cases. Prepectoral breast reconstruction using acellular dermal matrix inferiorly and Vicryl mesh superiorly is a safe technique that decreases material costs associated with support materials and allows the surgeon to precisely control the implant pocket and position. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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"To Pre or Not to Pre": Introduction of a Prepectoral Breast Reconstruction Assessment Score to Help Surgeons Solving the Decision-Making Dilemma. Retrospective Results of a Multicenter Experience. Plast Reconstr Surg 2021; 147:1278-1286. [PMID: 33973934 DOI: 10.1097/prs.0000000000008120] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction. METHODS Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed. RESULTS Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement. CONCLUSIONS To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient's risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Riis M. Management of patients with BRCA mutation from the point of view of a breast surgeon. Ann Med Surg (Lond) 2021; 65:102311. [PMID: 33996049 PMCID: PMC8091883 DOI: 10.1016/j.amsu.2021.102311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/24/2022] Open
Abstract
Germ-line mutation in BRCA (BReast CAncer gene) 1 or BRCA2 are found in 3–4% of all women with breast cancer. These patients have a significant increased risk of breast and ovarian cancer. They are often younger when diagnosed with the mutation, and the possible breast cancer they get is often aggressive with inferior outcome. There are risk reducing strategies, and the most powerful strategy is risk reducing surgery, both risk reducing bilateral mastectomy (RRM) and risk reducing bilateral salpino-oophorectomy (PBSO). This review is meant to address breast surgery in patients with germline BRCA mutation. The guidelines and techniques applied is under continuous change and it is important for the clinicians to be well informed to provide the patient with the information needed for them to make an informed decision on what risk strategy to choose. Patients with germ-line mutation in BRCA1 or BRCA2 have a significant increased risk of breast and ovarian cancer. There are different risk reducing strategies and the most powerful strategy is risk-reducing surgery, both risk reducing bilateral mastectomy and risk reducing bilateral salpingo-oophorectomy. Guidelines and techniques for the risk reducing surgery of the breast are under continuous change and improvement. Breast conserving therapy is not associated with worse survival and is a good option for a BRCA mutation carrier diagnosed with breast cancer. Risk-reducing mastectomy can be performed in a later setting. The management of BRCA mutation carriers, both affected and unaffected, should be performed in a multidisciplinary team. Physicians need to be systematically educated and updated on the most recent literature.
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Park JW, Seong IH, Lim W, Woo KJ. Pure hemi-periareolar incision versus conventional lateral radial incision mastectomy and direct-to-implant breast reconstructions: comparison of indocyanine green angiographic perfusion and necrosis of the nipple. Gland Surg 2020; 9:1193-1204. [PMID: 33224794 DOI: 10.21037/gs-20-506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study evaluated the feasibility of direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision without extension and with the aid of indocyanine green angiographic evaluation on the mastectomy skin flap. Methods Patients who underwent immediate direct-to-implant breast reconstruction from December 2018 to February 2020 were included. After nipple-sparing mastectomy, indocyanine green angiographic evaluation of perfusion to nipple-areola complex was performed by video recording with a near infrared camera, and nipple perfusion time and perfusion pattern were analyzed. Patients were divided into a pure hemi-periareolar incision group and conventional lateral radial incision groups to compare nipple perfusion and surgical outcomes. Results A total of 61 breasts in 56 patients were included. Pure hemi-periareolar incision was used in 41 breasts, and conventional lateral radial incisions were used in 20 breasts. Nipple perfusion time was significantly increased in the pure hemi-periareolar incision group (79.6±65.8 vs. 43.2±49.8 seconds, P=0.031). While minor nipple-areola complex necrosis was significantly increased in the pure hemi-periareolar incision group (19.5% versus 0%; P=0.044), major nipple-areola complex necrosis (2.4% versus 5.0%; P>0.999) was not significantly different between the two groups. The rates of nipple-areola complex necrosis were 0%, 16.7%, and 63.6% in rapid, delayed, and no perfusion groups, respectively (P<0.001). No nipple perfusion pattern was a significant predictor for nipple-areola complex necrosis in univariable and multivariable analyses (P<0.001). There was no case of reconstruction failure. Conclusions Immediate direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision can be safely performed using indocyanine green angiographic evaluation on the mastectomy skin flap.
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Affiliation(s)
- Jin-Woo Park
- Department of Plastic and Reconstructive Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ik Hyun Seong
- Department of Plastic and Reconstructive Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Woosung Lim
- Department of Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Kyong-Je Woo
- Department of Plastic and Reconstructive Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Salibian AA, Frey JD, Choi M, Karp NS. Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes. Aesthet Surg J 2020; 40:S1-S12. [PMID: 33202011 DOI: 10.1093/asj/sjaa130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.
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Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Mihye Choi
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Nolan S Karp
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
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Kim JH, Hong SE. A Comparative Analysis between Subpectoral versus Prepectoral Single Stage Direct-to-Implant Breast Reconstruction. MEDICINA-LITHUANIA 2020; 56:medicina56100537. [PMID: 33066236 PMCID: PMC7602109 DOI: 10.3390/medicina56100537] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 11/23/2022]
Abstract
Background and objectives: Until now subpectoral breast reconstruction (SBR) has been the predominant form; however, it can present with pectoralis muscle contraction and animation deformity. To avoid these complications, surgeons have begun placing breast implants in the same anatomic space as the breast tissue that was removed. We report a comparative analysis of prepectoral breast reconstruction (PBR) versus subpectoral breast reconstruction to analyze their differences. Materials and Methods: Direct-to-implant (DTI) reconstruction using acellular dermal matrix (ADM) performed from February 2015 to February 2020 were retrospectively reviewed. We then compared the clinical course and postoperative outcomes of the two groups (prepectoral vs. subpectoral) based on the overall incidence of complications, pain scale, and the duration of drainage. Results: A total of 167 patients underwent unilateral DTI, with SBR 114 (68.3%) and PBR 53 (31.7%). Patient demographics were similar between the two groups. There was no statistically significant difference in rates of seroma, infection (requiring intravenous antibiotics), hematoma, and skin necrosis. Implant loss rates in the SBR 6.1% (n = 7) and PBR 9.4% (n = 5) were also not statistically significant (p = 0.99). The hemovac duration period was significantly longer in the SBR (14.93 ± 5.57 days) group than in the PBR group (11.09 ± 4.82 days) (p < 0.01). However, post-operative pain scores are similar between two groups, although it is not clear whether this was due to the effect of postoperative patient-controlled analgesia. Conclusions: A SBR is a commonly used procedure with various advantages, but there are many problems due to damage to the normal pectoralis major muscle. According to the results of our study, the PBR group had a shorter hemovac duration period compared to the SBR group, although there was no significant difference in complication rate. A PBR is a simple and safe technique allowing early discharge without increasing the incidence of long-term complications.
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Mangialardi ML, Salgarello M, Baldelli I, Raposio E. Prepectoral implant pocket conversion in breast reconstruction. JPRAS Open 2020; 26:12-25. [PMID: 32995458 PMCID: PMC7502407 DOI: 10.1016/j.jpra.2020.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction While many authors have reported their experience in immediate prepectoral breast reconstruction (BR), implant pocket conversion from a submuscular to a prepectoral plane is less well described. The aim of this study is to provide a comprehensive review on plane conversion in implant-based BR, including the indications, surgical techniques, functional, and esthetic results. Materials and Methods A literature search via PubMed, Medline, Google Scholar, and Cochrane databases was performed using the following MeSH terms: “prepectoral pocket conversion”, “subcutaneous pocket conversion”, “prepectoral plane conversion”, “subcutaneous plane conversion”, and “prepectoral breast reconstruction”. Results Ten articles in which 504 breasts were studied were deemed eligible for inclusion. The indications to perform plane conversion were animation deformity (AD), chronic pain, and implant malposition. Seven studies described complete or partial capsulectomy. The use of acellular dermal matrices (ADM) was reported in all cases except for three studies. The mean follow-up was 10.64 months. There was resolution of AD in 100% of cases. Three studies reported complete resolution of chronic pain. The overall complication rate was 12.102% and capsular contracture (CC) was the most frequent complication. Cosmetic revisions were reported in six studies (9.52%). The use of ADMs and fat grafting appeared to decrease the rate of subsequent CC formation and cosmetic revisions. Conclusions The current article represents the first review about implant pocket conversion from a submuscular to a prepectoral plane, delineating its indications, surgical technique, postoperative complications, and functional and esthetic outcomes.
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Affiliation(s)
- Maria Lucia Mangialardi
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore e Unità di Chirurgia Plastica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Marzia Salgarello
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore e Unità di Chirurgia Plastica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Ilaria Baldelli
- Clinica di Chirurgia Plastica e Ricostruttiva, Ospedale Policlinico San Martino e Sezione di Chirurgia Plastica, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate - DISC, Università degli Studi di Genova, L.go R. Benzi 10, 16132 Genova, Italy
| | - Edoardo Raposio
- Clinica di Chirurgia Plastica e Ricostruttiva, Ospedale Policlinico San Martino e Sezione di Chirurgia Plastica, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate - DISC, Università degli Studi di Genova, L.go R. Benzi 10, 16132 Genova, Italy
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Wang X, Zhu K, Ren L, Li H, Lin S, Qing X, Wang J. Quality of life and related risk factors after breast reconstruction in breast cancer patients. Gland Surg 2020; 9:767-774. [PMID: 32775267 DOI: 10.21037/gs-20-532] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background Breast cancer is the most frequently occurring cancer in women globally, using radical mastectomy as the main clinical treatment. This study aims to investigate the quality of life and related factors in patients after breast reconstruction. Methods Female patients undergoing breast reconstruction after radical mastectomy between February 20, 2014 and February 20, 2019 in the Department of Tumor or the Department of Thyroid and Breast Surgery in the Affiliated Hospital of North Sichuan Medical College and Nanchong Central Hospital were surveyed. The patients' basic information was collected using a questionnaire prepared by the research team, and the Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire was used to assess the patients' quality of life. Multivariate linear regression analysis was performed to explore the factors impacting the change of FACT-B scores one year after surgery. Results A total of 150 patients were included. 143 of them had complete data, and 7 patients were lost to follow-up. Compared with the preoperative results, the scores of all dimensions of the FACT-B scale and the overall health status of the patients were significantly reduced at 3 months after surgery, which recovered to the preoperative level at 6 months after surgery (P<0.05), and significantly increased at 12 months after surgery (P<0.05). The results showed that age ≥40 years, menopause, postoperative complications, and endocrine therapy were risk factors for decreased quality of life at 12 months after breast reconstruction. Meanwhile, tumor stage 0 or stage I and immediate breast reconstruction were protective factors for quality of life at 12 months after breast reconstruction (P<0.05). Conclusions The postoperative quality of life of patients with breast reconstruction is relatively high. Older age, post-menopause, postoperative complications, endocrine therapy, advanced tumor stage, and delayed reconstruction are all risk factors for decreased quality of life of patients. Targeted measures should be taken to improve the postoperative life quality of patients, such as paying more attention to the older or post-menopausal patients, as well as those with postoperative complications, endocrine therapy, high tumor stage, or delayed breast reconstruction.
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Affiliation(s)
- Xiaoqing Wang
- Department of Thyroid and Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Kepeng Zhu
- Department of General Surgery, Nanchong Central Hospital, Nanchong 637000, China
| | - Liang Ren
- Department of Infection, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Hanbing Li
- Department of Thyroid and Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Shuai Lin
- Department of Thyroid and Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Xiao Qing
- Department of Thyroid and Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Jinlian Wang
- School of Nursing, North Sichuan Medical College, Nanchong 637000, China
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Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results. Plast Reconstr Surg 2020; 145:1343-1353. [PMID: 32459763 DOI: 10.1097/prs.0000000000006819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A growing number of transgender women present to plastic surgeons seeking breast augmentation. Despite some advocating their technical similarity, the authors have found substantially different planning and techniques are needed to obtain aesthetic results in transgender patients versus cosmetic breast augmentation. The authors sought to develop an approach for operative planning and technique to elucidate these differences and obtain consistent results. METHODS All patients who underwent breast augmentation at the Johns Hopkins Center for Transgender Health were included in this study. Anthropometric assessments were obtained and comparative statistics between operative and nonoperative cohorts were calculated. Outcomes were analyzed and a patient-reported survey was performed to evaluate patient satisfaction. RESULTS Fifty-nine consecutive transfemale patients presented for evaluation. Anthropometric measurements included base width (median, 15.0 ± 2.1 cm), notch-to-nipple distance (median, 22.0 cm), nipple-to-midline distance (median, 12.0 cm), areolar diameter (median, 3.5 ± 1.5 cm), and upper pole pinch (mean, 1.8 ± 1.1 cm). Thirty-six patients underwent augmentation mammaplasty. Postoperative complications (8.3 percent) included a minor hematoma and grade III capsular contracture in two patients. Patients were asked to complete a brief outcomes survey and reported an improvement in psychosocial well-being and high satisfaction rate (100 percent) with the overall cosmetic result. CONCLUSIONS Transgender female patients represent a unique patient population requiring special consideration of anatomical differences in key planning decisions. The authors delineate the first systematic algorithm that addresses these differences, emphasizing maneuvers such as routine inframammary fold lowering. This can allow experienced augmentation surgeons to obtain excellent aesthetic and patient-reported outcomes in this population. As with cosmetic breast augmentation, patient satisfaction rates are high. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Braun SE, Dreicer M, Butterworth JA, Larson KE. Do Nipple Necrosis Rates Differ in Prepectoral Versus Submuscular Implant-Based Reconstruction After Nipple-Sparing Mastectomy? Ann Surg Oncol 2020; 27:4760-4766. [PMID: 32699924 DOI: 10.1245/s10434-020-08887-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) has become increasingly popular, given its oncologic safety and preserved nipple areolar complex (NAC) aesthetics. Reconstruction has recently shifted from traditional submuscular (SM) to prepectoral (PP) implant placement. It remains unclear how the plane of implant placement might affect NAC perfusion. Our goal was to assess postoperative outcomes following NSM with SM versus PP implant placement. METHODS A retrospective single-institution review was performed of all patients undergoing NSM and immediate breast reconstruction in either the PP or SM plane from January 2015 to June 2019. Clinicopathologic details and 90-day complication rates were collected. SM and PP group complications were compared using Chi square analysis. RESULTS A total of 288 breasts (160 patients) were included, including SM in 79 cases (44 patients) and PP in 209 cases (116 patients). Clinicopathologic features between groups were similar. Overall, the rate of NAC necrosis was 15.1%, with no differences between the SM and PP cohorts (p = 0.79). In cases of NAC necrosis, there was no difference between the SM and PP groups in return to the operating room for debridement (p = 1.0) or explant (p = 0.33). CONCLUSIONS In our cohort, immediate implant-based reconstruction in the SM and PP planes following NSM was equally safe with respect to postoperative complications and NAC ischemia.
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Affiliation(s)
- Sterling E Braun
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Mollie Dreicer
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - James A Butterworth
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kelsey E Larson
- Division of Breast Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
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Abstract
Breast cancer is the most frequent cancer in women all over the world. The prognosis is generally good, with a five-year overall survival rate above 90% for all stages. It is still the second leading cause of cancer-related death among women. Surgical treatment of breast cancer has changed dramatically over the years. Initially, treatment involved major surgery with long hospitalization, but it is now mostly accomplished as an outpatient procedure with a quick recovery. Thanks to well-designed retrospective and randomly controlled prospective studies, guidelines are continually changing. We are presently in an era where safely de-escalating surgery is increasingly emphasized. Breast cancer is a heterogenous disease, where a "one-size-fits-all" treatment approach is not appropriate. There is often more than one surgical solution carrying equal oncological safety for an individual patient. In these situations, it is important to include the patient in the treatment decision-making process through well informed consent. For this to be optimal, the physician must be fully updated on the surgical options. A consequence of an improved prognosis is more breast cancer survivors, and therefore physical appearance and quality of life is more in focus. Modern breast cancer treatment is increasingly personalized from a surgical point of view but is dependent on a multidisciplinary approach. Detailed algorithms for surgery of the breast and the axilla are required for optimal treatment and quality control. This review illustrates how breast cancer treatment has changed over the years and how the current standard is based on high quality scientific research.
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Huang X, Cai XY, Liu JQ, Hao WW, Zhou YD, Wang X, Xu Y, Chen C, Lin Y, Wang CJ, Song Y, Sun Q. Breast-conserving therapy is safe both within BRCA1/2 mutation carriers and noncarriers with breast cancer in the Chinese population. Gland Surg 2020; 9:775-787. [PMID: 32775268 DOI: 10.21037/gs-20-531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background BRCA1/2 mutation is associated with a high risk of breast cancer, which may preclude breast cancer patients with BRCA1/2 mutation from breast-conserving therapy (BCT) [breast-conserving surgery (BCS), followed by radiotherapy, BCT]. It is debatable whether BCT could be a rational choice for Chinese breast cancer patients with a BRCA1/2 mutation. Methods The study comprised a cohort of women with invasive breast cancer either receiving BCT or mastectomy following the criteria for the germline BRCA1/2 mutation test. Germline DNA for BRCA1/2 testing was derived from blood samples. Survival analyses were performed. The correlations were analyzed between survival and distinct types of surgery. To compare the survival between different surgical management, Kaplan-Meier univariate analysis and multivariate Cox regression was used. Results In BRCA1/2 mutation carriers (N=176) and noncarriers (N=293), 25% and 27.3% of the patients received BCT, respectively (P=0.675). Patients receiving mastectomy (without radiotherapy or followed by radiotherapy) have larger tumor size (P<0.05 both in BRCA1/2 mutation carriers and noncarriers), prognostically worse tumor characteristics including significantly more advanced TNM stage (P=0.017 and P<0.0001 respectively) and more positive lymph nodes (P=0.008 and P<0.0001, respectively) both in BRCA1/2 mutation carriers and noncarriers. Still, more often received systemic therapy has also been observed. After adjustment for clinical-pathological characteristics and systemic treatment, patients who received BCT had a similar breast cancer disease-free survival compared with patients who received mastectomy, both in BRCA1/2 mutation carriers and noncarriers [HR BRCA1/2 =1.17, confidence interval (CI): 0.57-2.39, P=0.68; HRnoncarriers =0.91, CI: 0.47-1.77, P=0.79, respectively). The recurrence free survival after BCT did not differ from mastectomy in BRCA1/2 mutation carriers [BCT, 5-year cumulative recurrence-free survival (RFS) =0.95, CI: 0.89-1.00; mastectomy, 5-year cumulative RFS =0.93, CI: 0.85-1.00], even better for BCT in noncarriers (BCT, 5-year cumulative RFS =0.67, CI: 0.42-0.89; mastectomy, 5-year cumulative RFS =0.83, CI: 0.71-0.95). Conclusions Thus, BCT may be a safe and rational choice for Chinese female breast cancer patients with a BRCA1/2 mutation. However, tumor size, the TNM stage, the number of positive lymph nodes, might be taken into consideration when choosing surgical management.
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Affiliation(s)
- Xin Huang
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Xiu-Yu Cai
- Department of VIP Region, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jia-Qi Liu
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Wen Hao
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yi-Dong Zhou
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Xiang Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Xu
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Chang Chen
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Yan Lin
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Chang-Jun Wang
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Yu Song
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
| | - Qiang Sun
- Departments of Breast Surgery, Peking Union Medical College Hospital, Xicheng District, Beijing, China
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Skin-Reducing Mastectomy and Pre-pectoral Breast Reconstruction in Large Ptotic Breasts. Aesthetic Plast Surg 2020; 44:664-672. [PMID: 31970455 DOI: 10.1007/s00266-020-01616-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Pre-pectoral breast reconstruction is increasingly offered to breast cancer patients, as the one-stage technique has proved surgical and oncological safety and aesthetic effectiveness. Nevertheless, there are limited data on outcomes after pre-pectoral breast reconstruction in large and ptotic breasts. The aim of the paper is to present the authors' experience in performing Wise pattern mastectomy with pre-pectoral implant and complete acellular dermal matrix (ADM) coverage as a single-stage procedure in patients with large ptotic breasts. MATERIALS AND METHODS A retrospective review of protective collected data from January 2017 to June 2019 of patients who presented with large and ptotic breasts undergoing skin-reducing mastectomy and immediate pre-pectoral breast reconstruction with complete ADM coverage and inferior dermal sling was performed. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through BREAST-Q questionnaire. RESULTS Nineteen patients met the inclusion criteria. The average patient age was 55.6 years, and the mean body mass index was 31.2. Mean follow-up was 23.2 months from the initial reconstruction. One patient experienced seroma, and two cases of wound dehiscence at the T junction were observed and treated conservatively with no implant loss. All patients were satisfied with the final reconstruction. CONCLUSION The Wise pattern skin-reducing mastectomy and pre-pectoral breast reconstruction could be offered to patients presenting with large and ptotic breasts. Future studies should better define long-term outcomes. 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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ADM-assisted prepectoral breast reconstruction and skin reduction mastectomy: Expanding the indications for subcutaneous reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:673-680. [DOI: 10.1016/j.bjps.2019.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 08/07/2019] [Accepted: 11/22/2019] [Indexed: 12/12/2022]
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Tradeoffs in Implant Selection for Reconstructive Surgery and Adjuncts Utilized to Maximize Aesthetic Outcomes. Plast Reconstr Surg 2019; 144:51S-59S. [DOI: 10.1097/prs.0000000000005950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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