Robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with gel implant and latissimus dorsi muscle flap: Our initial experience

BACKGROUND

This study reports the preliminary results of da Vinci robot XI robot-assisted nipple-sparing mastectomy immediate breast reconstruction (R-NSMIBR) with gel implant and latissimus dorsi muscle flap.

METHODS

A total of 15 patients who underwent R-NSMIBR with gel implant and latissimus dorsi muscle flap surgery for breast cancer between September 2022 and November 2022 were evaluated.

RESULTS

Mean total operative time for R-NSMIBR was 361.9 ± 77.0 min. As the learning curve increased, the robot arm docking time decreased rapidly from the initial 25-10 min. Average total blood loss was 27.8 ± 10.7 mL and posterior surgical margin positivity rate was 0%. Perioperative complications and local recurrences or deaths were not observed at a mean follow-up of 3 ± 1 month 15 patients were satisfied with postoperative aesthetic results.

CONCLUSIONS

R-NSMIBR with a gel implant and latissimus dorsi muscle flap could be a new therapeutic option for breast reconstruction.

Soft-tissue sarcoma of the arm-An oncosurgical and reconstructive challenge: A case report

Soft-tissue sarcoma (STS) is a rare tumor that may occur in the upper extremity. Its presentation is delayed by slow growth and lack of symptoms. Lesions are discovered via physical and radiologic examinations, and definitive diagnosis is conducted histopathologically. We present the case of a 63-year-old man with swelling of the dorsum of the arm,nocturnal hyperhidrosis, and weight loss. Radiologic examination revealed possible malignancy and metabolically active left axillary lymph nodes. The tumor was excised, and the defect was covered using a pedicled myocutaneous latissimus dorsi flap. The distal portion of the muscle was attached to the remnant tricep brachii tendon. Postoperative histopathology revealed a highly malignant STS. The patient remained relapse-free after a regimen for adjuvant chemotherapy. Satisfactory aesthetic results and modest elbow extension were evident during the 11-month follow-up. Properly managing upper extremity STS is crucial for preventing recurrence and metastasis.

The Influence of Functional Shoulder Biomechanics as a Mediator of Patient-Reported Outcomes following Mastectomy and Breast Reconstruction

BACKGROUND

Postmastectomy breast reconstruction techniques differentially influence patient-reported physical and psychosocial well-being. Objective measures of shoulder biomechanics, which are uniquely influenced by reconstruction technique, may provide insight into the influence of reconstruction technique on patient-reported outcomes.

METHODS

Robot-assisted measures of shoulder strength and stiffness, and five validated patient-reported outcomes surveys were obtained from 46 women who had undergone mastectomy and a combined latissimus dorsi flap plus subpectoral implant, subpectoral implant, or DIEP flap breast reconstruction. Mediation analyses examined the role of functional shoulder biomechanics as a mediator between reconstruction technique and patient-reported outcomes.

RESULTS

Reconstruction technique affected shoulder biomechanics, with latissimus dorsi flap plus subpectoral implant patients exhibiting reduced shoulder strength and stiffness compared with subpectoral implant and DIEP flap patients. Increasing external rotation strength was predictive of improved upper extremity function (p = 0.04). Increasing shoulder stiffness while at rest was predictive of worsened upper extremity function (p = 0.03). Increasing shoulder stiffness at rest and during contraction was indicative of worsened psychosocial well-being (all p ≤ 0.02). Reconstruction technique did not predict survey scores of function directly, or when mediated by functional shoulder biomechanics.

CONCLUSIONS

In the current cohort, latissimus dorsi plus subpectoral implant breast reconstructions significantly reduced shoulder strength and stiffness when compared with the other techniques. In addition, objective measures of shoulder biomechanics were predictive of patient-reported physical and psychosocial well-being. The results emphasize the need for improved perioperative screening for shoulder functional deficits in patients undergoing breast reconstruction.

CLINICAL QUESITON/LEVEL OF EVIDENCE

Therapeutic, II.

Recurrent syringomatous adenoma of the nipple following a misdiagnosis: A case report

Infiltrating syringomatous adenoma of the nipple (SAN) is a rare benign neoplasm of the breast that is often misdiagnosed. SAN may present with a subareolar lesion and clinical, mammographic, and ultrasonographic findings associated with malignancy. We present the case of a 60-year-old woman with a painful, firm, solid tumor in her left breast and deformation of the left nipple-areolar complex (NAC). Histopathological test results were conflicting. The tumor, including the NAC were locally excised. Postsurgical immuno-histochemical tests revealed squamous histology, whereas myoepithelial cells were present in the resected specimen, a feature consistent with SAN. The pathologist noted microscopically positive surgical margins. Three months after surgery, tumor recurrence occurred. The patient underwent revision surgery with wide excision of the skin and gland around the lesion, followed by immediate breast reconstruction, using a pedicled myocutaneous latissimus dorsi (pLD) flap. Extreme care should be taken when diagnosing SAN to ensure proper treatment and prevent recurrence.

Scalp Reconstruction after Malignant Tumor Resection: An Analysis and Algorithm

Background  An oncologic tumor resection of the scalp can result in complex wounds that result in challenging scalp reconstructions. This study aimed to evaluate the outcomes of microvascular-based scalp reconstructions (MSR) in oncologic patients and to propose an algorithmic treatment approach. Methods  Within a 5-year period, 38 patients having undergone 41 MSR (15 anterolateral thigh (ALT), 15 gracilis muscle (GM), and 11 latissimus dorsi muscle (LDM) flaps) after extensive scalp tumor resections fulfilled inclusion criteria for this study. Results  Malignant skin disease included superficial and/or deep infiltration of the calvarium in 26 and combined intracranial infiltration in 12 patients. In case of bone replacement (24 patients), MSR was done concomitant, otherwise MSR was performed after pathological confirmation of tumor-free margins. LDM flaps were used in cases with defect sizes of 400 to 1250cm ² , whereas ALT- and GM flaps were chosen for defects ranging from 40 to 350cm ² . The average length of the pedicle was comparable in ALT- and LDM flaps and longer than in GM flaps. Total flap loss with need for revision surgery and minor donor site morbidity occurred in four and three patients, respectively. Conclusion  Microsurgical reconstruction of moderate-to-extensive scalp defects remains a reliable method with overall low risks and satisfactory aesthetic results, while, according to our experience, muscle flaps show the best functional and aesthetic results. However, in cases of central scalp defects and in situations when a long vascular pedicle of the flap is important, the ALT flap seems to be the best solution.

[Breast reconstruction surgery with endoscopic assisted latissimus dorsi muscle flap]

The results obtaining with breast reconstruction surgery are not always satisfactory for the patients. Reconstruction with pure latissimus dorsi flap is useful option and due to endoscopic harvest large scar on the back can be avoided. The skin sparing mastectomy and even the sentinel lymph node biopsy or lymphadenectomy can be performed using a single incision in the axilla. Also the immediate reconstruction with endoscopically assisted harvest of the latissimus dorsi muscle flap in selective cases can be done using the same incision. The patient reported high satisfaction with the aesthetic and functional results due to preservation the breast shape and the absence of any scarring on the back.

The Clinical Application of Mastectomy With Single Incision Followed by Immediate Laparoscopic-Assisted Breast Reconstruction With Latissimus Dorsi Muscle Flap

OBJECTIVE

To explore the clinical application of mastectomy with single incision followed by immediate laparoscopic-assisted breast reconstruction with latissimus dorsi muscle flap.

METHODS

Fifteen women with primary early breast cancer, 3 women with breast ductal carcinoma in situ, and 7 women with severe plasma cell mastitis were treated with partial mastectomy or total mastectomy, sentinel lymph node biopsy, or axillary lymph node dissection through a breast lateral transverse incision. Subsequent breast reconstruction with latissimus dorsi muscle flap was assisted by laparoscopy. The patient's position, time used in dissecting latissimus dorsi muscle flap, size of latissimus dorsi muscle flap, postoperative complications, and the cosmetic results after reconstruction were assessed.

RESULTS

All the operations were well done through the breast lateral transverse incision and assistance of laparoscopy. The patient's position was changed only once during the operation. It took 1.5 to 2 hours to dissect latissimus dorsi muscle flap. The sizes of the latissimus dorsi muscle flap were 5 to 8 × 12 to 16 cm. There were no serious postoperative complications noted. The patients were satisfied with the appearance of the breasts and the small surgical scar.

CONCLUSION

The surgical approach introduced is minimally invasive with concealed scar and outstanding cosmetic results. It is worth promoting in clinical application.