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Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4307. [PMID: 35702357 PMCID: PMC9187185 DOI: 10.1097/gox.0000000000004307] [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: 11/19/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
Abstract
Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow.
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Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes. Plast Reconstr Surg 2021; 148:1173-1185. [PMID: 34644280 DOI: 10.1097/prs.0000000000008282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. METHODS A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. RESULTS Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. CONCLUSIONS Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Sultan SM, Rizzo AM, Erhard HA, Benacquista T, Weichman KE. Revisiting the internal mammaries as recipient vessels in breast reconstruction: considerations in current practice. Breast Cancer Res Treat 2020; 184:255-264. [PMID: 32888141 DOI: 10.1007/s10549-020-05878-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 08/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future. METHODS The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009-2011, 2011-2013, 2014-2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology's atheroscletoric and cardiovascular disease (ASCVD) risk calculator. RESULTS There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009-2011, n = 55; 2012-2014, n = 50; 2015-2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009-2011 = 32.7%, 2012-2014 = 28.0%, 2015-2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009-2011 = 25.5%, 2012-2014 = 20.0%, 2015-2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups. CONCLUSION Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.
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Affiliation(s)
- Steven M Sultan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Amanda M Rizzo
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Heather A Erhard
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Teresa Benacquista
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Katie E Weichman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Kim EK, Cho JM, Lee JW. Skin-sparing Mastectomy and Immediate Nipple Graft for Large, Ptotic Breast. J Breast Cancer 2020; 22:641-646. [PMID: 31897337 PMCID: PMC6933028 DOI: 10.4048/jbc.2019.22.e52] [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: 06/05/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022] Open
Abstract
Nipple-areolar skin-sparing mastectomy followed by autologous reconstruction in patients with large, ptotic breasts often offers a limited field, resulting in strenuous traction. Skin-sparing mastectomy (SSM) with immediate nipple grafting from the specimen was attempted for such patients. Patients who underwent SSM with immediate autologous breast reconstruction and nipple grafting between September 2016 and February 2019 were evaluated, including 33 nipple grafts in 30 patients. The average weight of the mastectomy specimen was 552.5 g and the average operation time for unilateral mastectomy was 109 minutes. No complete nipple loss or major skin flap necrosis was reported. Adjuvant therapy started after an average of 24 days. SSM with immediate nipple grafting on the autologously reconstructed breast could be an alternative for large, ptotic breasts. It is also useful for patients requiring contralateral balancing procedures or those with bilateral breast cancer in which only one nipple can be spared oncologically.
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Affiliation(s)
- Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Mok Cho
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Yang CQ, Ji F, Gao HF, Zhang LL, Yang M, Zhu T, Chen MY, Li JQ, Wang K. The Role of Sharp Dissection in Nipple-Sparing Mastectomy: A Safe Procedure with No Necrosis of the Nipple-Areolar Complex. Cancer Manag Res 2019; 11:10223-10228. [PMID: 31824192 PMCID: PMC6900313 DOI: 10.2147/cmar.s230787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/20/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nipple-sparing mastectomy (NSM) is becoming increasingly accepted as a treatment for breast disease; however, nipple-areolar complex (NAC) necrosis, a frequent severe postoperative complication, inhibits the popularity of this procedure. This study reports the technical aspects and short-term postoperative outcomes of NSM. Methods A single-center, retrospective review of 110 patients treated with NSM at our institution from November 2015 to September 2018 was performed. The primary outcome was the incidence of NAC necrosis. Results A total of 130 NSMs performed on 110 patients were included in our study. Median patient age was 42 years. We performed a sharp dissection by using a scalpel, raising 3–5 mm thick flaps, and continuing onto the undersurface of the NAC. None of the 110 patients appeared to have NAC necrosis or mastectomy skin flap necrosis. However, discoloration or ischemia of the NAC with eschar formation presented between postoperative days 3 and 7 in six nipples; four nipples were ischemic, and two were discolored. No infection was detected in any of the 110 patients. All NACs were intact after an average follow-up of 30 months, and no local or systemic recurrence was detected in those breast cancer cases. Conclusion NSM can be safely performed in properly selected patients. Nipple necrosis was avoided using a special surgical technique, and other complications occurred at an acceptable rate.
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Affiliation(s)
- Ci-Qiu Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Fei Ji
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Hong-Fei Gao
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Liu-Lu Zhang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Mei Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Teng Zhu
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Min-Yi Chen
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jie-Qing Li
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Kun Wang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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Moon KC, Lee JM, Baek SO, Jang SY, Yoon ES, Lee BI, Park SH. Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study. Arch Plast Surg 2019; 46:140-146. [PMID: 30934178 PMCID: PMC6446025 DOI: 10.5999/aps.2018.00913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Thoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap. METHODS A retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups. RESULTS No statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group. CONCLUSIONS The results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.
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Affiliation(s)
- Kyung-Chul Moon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae-Min Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Si-Ook Baek
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seo-Yoon Jang
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Eul-Sik Yoon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Byung-Il Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seung-Ha Park
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
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Sasaki Y, Madada-Nyakauru RN, Samaras S, Oni G, Di Candia M, Malata CM. The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation. J Plast Reconstr Aesthet Surg 2019; 72:1000-1006. [PMID: 30824382 DOI: 10.1016/j.bjps.2019.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 12/27/2018] [Accepted: 01/06/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ± 3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ± 26.7) and third (46.5 mins ± 31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.
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Affiliation(s)
- Y Sasaki
- Department of Plastic Surgery, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - R N Madada-Nyakauru
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - S Samaras
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - G Oni
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - M Di Candia
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; University Department of Plastic Surgery, University di Bari, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - C M Malata
- Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK; Anglia Ruskin University School of Medicine, Cambridge and Chelmsford, East Road, Cambridge, UK.
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Examining Length of Hospital Stay after Microsurgical Breast Reconstruction: Evaluation in a Case-Control Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1588. [PMID: 29632768 PMCID: PMC5889468 DOI: 10.1097/gox.0000000000001588] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 10/04/2017] [Indexed: 11/21/2022]
Abstract
Background: While possessing numerous benefits, microsurgical breast reconstruction is associated with longer operative times and post-operative hospital length of stay compared to implant-based reconstruction. We therefore evaluate factors associated with increased length of stay (LOS) after microsurgical breast reconstruction with a case-control study design. Methods: All patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction over a two-year time period were identified. Risk factors associated with LOS greater than or equal to 5 days were identified. Results: A total of 116 patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction were identified. Of these, 86 (74.1%) had a LOS of 4 days or less (mean: 3.70 days) while 30 (25.9%) had a LOS of 5 days or greater (mean: 5.50 days). With regards to patient demographics and intra-operative factors, patients with a LOS of 5 days or greater were significantly more likely to have diabetes mellitus (p < 0.0001), undergo bilateral reconstruction (p = 0.0003) and total mastectomy (p < 0.0001), and have a longer operative time (p < 0.0001) while significantly less likely to undergo post-operative radiation (p = 0.0421). Notably, there was no significant difference between the groups in terms of follow-up time, or time since breast reconstruction (p = 0.0600). With regards to reconstructive complications, patients with LOS of 5 days of greater were significantly more likely to experience abdominal donor site abscess (p < 0.0001), breast hematoma (p = 0.0186), and return to the operating room for flap compromise (p < 0.0001). Conclusions: Multiple patient-specific, intra-operative, and post-operative outcomes factors are associated with increased length of stay with immediate and delayed microsurgical breast reconstruction.
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Knackstedt R, Hashem AM, Schwarz GS. Nipple sparing mastectomy and microsurgical breast reconstruction: An approach for success. J Plast Reconstr Aesthet Surg 2017; 71:609-611. [PMID: 28988598 DOI: 10.1016/j.bjps.2017.08.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 08/03/2017] [Accepted: 08/26/2017] [Indexed: 11/19/2022]
Affiliation(s)
| | - Ahmed M Hashem
- Department of Plastic and Reconstructive Surgery, Cairo University, Cairo, Egypt
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Samargandi OA, Winter J, Corkum JP, Al Youha S, Frank S, Williams J. Comparing the thoracodorsal and internal mammary vessels as recipients for microsurgical autologous breast reconstruction: A systematic review and meta-analysis. Microsurgery 2017; 37:937-946. [PMID: 28949034 DOI: 10.1002/micr.30244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/14/2017] [Accepted: 09/05/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Our aim was to determine whether the thoracodorsal (Td) vessels have comparable clinical outcomes to the internal mammary (IM) vessels as recipients for autologous free tissue transfer for breast reconstruction. METHODS Systematic searches of MEDLINE, EMBASE, CENTRAL, and World of Science from inception to June 2016 were performed by two independent reviewers. Studies that included adult females undergoing autologous free tissue transfer for breast reconstruction were selected. The two comparison groups were the use of IM or Td as recipient vessels. Our primary outcome was rate of flap survival. We assessed the methodologic quality of included studies using the JADAD and MINOR scales. RESULTS A total of 1897 patients underwent 2644 free abdominal flap tissue transfer in the 10 articles that were included in our analysis. There was one randomized controlled study (Jadad score 2/5) and 9 nonrandomized controlled studies (MINORS scores 11-19/24). There was no difference between the uses of either vessel in terms of flap loss (1.18; 95% CI 0.71-1.95). Complication rate among the IM vessels ranged from 5 to 12%, compared with 3.4-12% among Td vessels. Hematoma and seroma rates were variable. Fat necrosis was higher with Td vessels in two studies. Performing Td vessels anastomosis was associated with shorter operative time and higher risk of encountering unusable vessel. CONCLUSION Both recipient vessels are safe, reliable and demonstrate equivocal results in the absence of contraindications. Utilizing either as a first-line vessel is reasonable, depending on surgeons' preference or certain clinical scenarios. QUESTION Therapeutic, Level of evidence: III.
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Affiliation(s)
- Osama A Samargandi
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Plastic and Reconstructive Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jessica Winter
- Department of Surgery, Section of Plastic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph P Corkum
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah Al Youha
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Simon Frank
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Plastic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jason Williams
- Division of Plastic Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies. Plast Reconstr Surg 2017; 139:1300-1310. [DOI: 10.1097/prs.0000000000003340] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures. Arch Plast Surg 2016; 43:328-38. [PMID: 27462565 PMCID: PMC4959975 DOI: 10.5999/aps.2016.43.4.328] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 05/18/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4–156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.
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Abstract
INTRODUCTION Besides the diffusion of breast reconstructive techniques, several "conservative" approaches in mastectomy have been developed, in order to perform an immediate reconstruction with better aesthetic results: the skin-sparing mastectomy (SSM), the nipple-areola complex (NAC)-sparing mastectomy (NSM) and the skin-reducing mastectomy (SRM). During the last decade, SSMs and NSMs have gained widespread acceptance and are currently considered standard treatment for early breast cancer. We would like to investigate the evidence behind this radical shift towards conservative mastectomies, where there has been a renewed interest worldwide. METHODS We reviewed English literature by consulting the following databases: Medline, Embase, Cochrane Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal and Clinicaltrials.gov. The objective is to include any randomized controlled trial (RCT) comparing a "conservative mastectomy" technique to breast conservative surgery or modified radical mastectomy (MRM) for the treatment of early-stage breast cancer. In the absence of randomized trials, we took into account prospective cohorts and retrospective series for a narrative description of available evidence. RESULTS Our review included 58 studies [19 prospective cohorts (34%) and 39 retrospective series (66%)] considering NSM and immediate reconstruction and ten studies [1 prospective cohort (10%) and 9 (90%) retrospective series] considering SSM and immediate reconstruction. In the NSM group, 29 studies reported data about complication rates and 42 studies presented data on NAC partial or complete necrosis. In the NSM group 45 studies and all the studies in the SSM group presented data on local and NAC recurrence. CONCLUSIONS In order to achieve higher levels of evidence, RCTs comparing conservative mastectomies to traditional mastectomy and breast conservative surgery would be desirable. However we can conclude that conservative mastectomies offer the psychological advantages of good cosmetics and maintenance of woman body image without compromising the oncological safety of mastectomy.
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Affiliation(s)
- Nicola Rocco
- 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131 Naples, Italy ; 2 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122 Milano, Italy
| | - Giuseppe Catanuto
- 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131 Naples, Italy ; 2 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122 Milano, Italy
| | - Maurizio Bruno Nava
- 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Via S. Pansini 5, 80131 Naples, Italy ; 2 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122 Milano, Italy
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Approaches to Microvascular Breast Reconstruction After Total Skin-Sparing Mastectomy. Ann Plast Surg 2015; 74 Suppl 1:S46-51. [DOI: 10.1097/sap.0000000000000391] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim DY, Lee TJ, Kim EK, Yun J, Eom JS. Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: A systematic review. Plast Surg (Oakv) 2015; 23:255-259. [PMID: 26665142 PMCID: PMC4664142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed. OBJECTIVES To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods. METHODS Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: "DIEP" or "free TRAM" and "venous insufficiency" or "venous congestion". Supplemental searches were conducted to identify referenced studies. Statistical analysis using the χ(2) test was performed. RESULTS Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency. CONCLUSION The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.
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Affiliation(s)
- Deok-Yeol Kim
- Department of Plastic and Reconstructive Surgery, Korea University Guro Hospital
| | - Taik Jong Lee
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Jiyoung Yun
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Jin Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
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Munhoz AM, Montag E, Filassi JR, Gemperli R. Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques. World J Clin Oncol 2014; 5:478-494. [PMID: 25114861 PMCID: PMC4127617 DOI: 10.5306/wjco.v5.i3.478] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 01/24/2014] [Accepted: 05/16/2014] [Indexed: 02/06/2023] Open
Abstract
Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon’s experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon’s experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.
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Santanelli di Pompeo F, Longo B, Laporta R, Pagnoni M, Cavalieri E. The use of the serratus anterior muscle vascular pedicle as recipient site in DIEP flap transfer for breast reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:456-60. [PMID: 24529692 DOI: 10.1016/j.bjps.2013.12.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/31/2013] [Accepted: 12/21/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Fabio Santanelli di Pompeo
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy.
| | - Benedetto Longo
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Rosaria Laporta
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Marco Pagnoni
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Enrico Cavalieri
- Plastic Surgery Unit 'Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
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Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg 2014; 132:1043-1054. [PMID: 23924650 DOI: 10.1097/prs.0b013e3182a48b8a] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy is a controversial option for breast cancer treatment due to locoregional recurrence and distant metastasis. In addition to these oncologic factors, technical factors such as ideal incision type or reconstructive options are also debatable. This systematic review examines current trends with nipple-sparing mastectomy, including selection criteria, locoregional and distant metastasis rates, incision choice, and reconstructive options. METHODS Systematic electronic searches were performed in the PubMed and Ovid databases using search terms for studies reporting outcomes following nipple-sparing mastectomy and all forms of reconstruction. Studies between 1970 and 2013 were reviewed. Pooled descriptive statistics with separate analyses for incision type and reconstructive method were performed. RESULTS Forty-eight studies met inclusion criteria, yielding 6615 nipple-sparing mastectomies for analysis. The overall pooled complication rate was 22 percent, the nipple necrosis rate was 7 percent, the locoregional recurrence rate was 1.8 percent, and the distant metastasis rate was 2.2 percent. Comparing combined patient cohorts for two-stage expander to implant, one-stage direct to implant, and autologous reconstruction demonstrated overall complication rates of 52.8, 16.7, and 23.7 percent and nipple necrosis rates of 4.5, 4.1, and 17.3 percent, respectively. Incision types were divided into five categories: radial, periareolar/circumareolar, inframammary, mastopexy, and transareolar, with nipple necrosis rates of 8.83, 17.81, 9.09, 4.76, and 81.82 percent, respectively CONCLUSIONS Nipple-sparing mastectomy appears to be an oncologically safe option for properly selected patients, with low rates of locoregional and distant metastasis. Overall complication and nipple necrosis rates are affected by incision location and reconstruction method. Randomized controlled trials are warranted to determine best incision and reconstructive methods. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Lee KT, Pyon JK, Bang SI, Lee JE, Nam SJ, Mun GH. Does the reconstruction method influence development of mastectomy flap complications in nipple-sparing mastectomy? J Plast Reconstr Aesthet Surg 2013; 66:1543-50. [DOI: 10.1016/j.bjps.2013.06.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 06/10/2013] [Accepted: 06/17/2013] [Indexed: 11/30/2022]
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