Friday, 14 December 2018

What’s new in oncology: Breast Cancer


What's new in oncology  (UpToDate – you *may* need to be logged into UpToDate before accessing these links. You can access via Zenworks (on a Trust computer) and then register for your own account which enables you to use the app and collect CPD points)

Literature review current through: Nov 2018. | This topic last updated: Dec 12, 2018.


Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm

by Frey, Jordan D.; Salibian, Ara A.; Levine, Jamie P.; Karp, Nolan S.; Choi, Mihye  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 826e–835e

Background: Nipple-sparing mastectomy allows for preservation of the entire nipple-areola complex using various incision patterns. Reconstructive trends and overall risk associated with these diverse nipple-sparing mastectomy incisions have yet to be fully elucidated.
Methods: All nipple-sparing mastectomies from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar.
Results: A total of 1207 nipple-sparing mastectomies were included for final analysis. Of these, 638 (52.9 percent) used an inframammary fold incision, 294 (24.4 percent) used a lateral radial incision, 161 (13.3 percent) used a vertical radial incision, 60 (5.0) used a Wise pattern incision, 35 (2.9 percent) used a previous incision, and 19 (1.6 percent) used a periareolar incision. The groups were heterogeneous and differed significantly with regard to various factors, including age (p < 0.001), body mass index (p < 0.001), reconstruction modality (p < 0.001), and others. In crude multivariate logistic regression analysis, vertical radial (16.1 percent) and inframammary fold incisions (21.0 percent) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p = 0.001) emerged as significantly protective of overall complications after controlling all variables.
Conclusions: Nipple-sparing mastectomy may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with the lowest risk, whereas Wise pattern incisions may increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction

 by Beugels, Jop; Vasile, Julie V.; Tuinder, Stefania M. H.; Delatte, Stephen J.; St-Hilaire, Hugo; Allen, Robert J.; Levine, Joshua L.  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1424–1434

Background: Options for bilateral autologous breast reconstruction in thin women are limited. The aim of this study was to introduce a novel approach to increase abdominal flap volume with the stacked hemiabdominal extended perforator (SHAEP) flap. The authors describe the surgical technique and analyze their results.
Methods: A retrospective study was conducted of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap reexplorations were recorded. The bipedicled hemiabdominal flap was designed as a combination of the deep inferior epigastric artery perforator (DIEP) and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator.
Results: A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 minutes (range, 405 to 797 minutes). Median hemiabdominal flap weight that was used for reconstruction was 598 g (range, 160 to 1389 g). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 percent), hematoma (3.3 percent), fat necrosis (2.2 percent), and wound problems (4.4 percent). Minor donor-site complications occurred in five patients (10.2 percent). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels.
Conclusions: This study demonstrated that the SHAEP flap is an excellent option for bilateral autologous breast reconstruction in women who require significant breast volume but have insufficient abdominal tissue for a bilateral DIEP flap. The bipedicled SHAEP flap allows for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction

by Torabi, Radbeh; Stalder, Mark W.; Tessler, Oren; Bartow, Matthew J.; Lam, Jonathan; Patterson, Charles; Wise, M. Whitten; Dupin, Charles L.; St. Hilaire, Hugo  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 840e–846e

Background: Breast cancer is primarily a diagnosis of older women. Many patients seeking breast reconstruction are elderly women (aged 65 years or older). However, many surgeons anecdotally believe that surgery in elderly patients is inherently dangerous, or at least prone to more complications. 
Methods: The authors conducted a retrospective cohort study composed of chart review of all deep inferior epigastric perforator flap breast reconstruction patients at a single institution divided into an elderly cohort (65 years or older) and a nonelderly cohort (younger than 65 years). Cohort was the primary predictor variable. Demographic and comorbidity data were secondary predictor variables. Primary outcomes were complete flap loss, partial flap loss, or need for flap reexploration. Secondary outcomes such as wound healing problems, seroma, and others were also assessed. 
Results: There were 285 flaps in the nonelderly cohort and 54 flaps in the elderly cohort. The elderly cohort had higher rates of diabetes, hypertension, and hyperlipidemia. Chi-square analysis showed no significant differences in primary outcomes between the two cohorts. Breast wound dehiscence was significantly higher in the elderly cohort (p < 0.01). On logistic regression, being elderly was seen as a significant risk factor for complete flap loss (OR, 10.92; 95 percent CI, 0.97 to 122.67; p = 0.05). The overall success rate for the nonelderly cohort was 99.6 percent, whereas the success rate for the nonelderly cohort was 96.3 percent. 
Conclusions: Elderly women desire breast reconstruction. Free flap breast reconstruction is a viable and safe procedure in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Modern Primary Breast Augmentation: Best Recommendations for Best Results

 by Wan, Dinah; Rohrich, Rod J.  

Learning Objectives: After reading this article, the participant should be able to: 
1. Develop a practical method for preoperative implant size selection. 
2. List characteristics and examples of fourth- and fifth-generation silicone implants. 
3. Recognize the differences in “profile” designations across implant manufacturers. 
4. Recall updated statistics on breast implant–associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 
5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation. 

Summary: Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and “profile” types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant–associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant–associated anaplastic large cell lymphoma.

Fat Graft Safety after Oncologic Surgery: Addressing the Contradiction between In Vitro and Clinical Studies

by Orbay, Hakan; Hinchcliff, Katharine M.; Charvet, Heath J.; Sahar, David E.  

Background: The authors investigate the in vitro and in vivo interaction of human breast cancer cells and human adipose-derived stem cells to address the controversy on the safety of postmastectomy fat grafting. Methods: The authors co-cultured human adipose-derived stem cells and MDA-MB-231 breast cancer cells in an in vitro cell migration assay to examine the migration of breast cancer cells. In the in vivo arm, the authors injected breast cancer cells (group I), human breast cancer cells plus human adipose-derived stem cells (group II), human breast cancer cells plus human fat graft (group III), and human breast cancer cells plus human fat graft plus human adipose-derived stem cells (group IV) to the mammary fat pads of female nude mice (n = 20). The authors examined the tumors, livers, and lungs histologically after 2 weeks. Results: Migration of breast cancer cells increased significantly when co-cultured with adipose-derived stem cells (p < 0.05). The tumor growth rate in group IV was significantly higher than in groups I and II (p < 0.05). The tumor growth rate in group III was also higher than in groups I and II, but this difference was not statistically significant (p > 0.05). Histologically, there was no liver/lung metastasis at the end of 2 weeks. The vascular density in the tumors from group IV was significantly higher than in other groups (p < 0.01). Conclusion: The injection of breast cancer cells, fat graft, and adipose-derived stem cells together increases breast cancer xenograft growth rates significantly.

[Articles] Neoadjuvant chemotherapy with or without anthracyclines in the presence of dual HER2 blockade for HER2-positive breast cancer (TRAIN-2): a multicentre, open-label, randomised, phase 3 trial

 by Mette S van Ramshorst, Anna van der Voort, Erik D van Werkhoven, Ingrid A Mandjes, Inge Kemper, Vincent O Dezentjé, Irma M Oving, Aafke H Honkoop, Lidwine W Tick, Agnes J van de Wouw, Caroline M Mandigers, Laurence J van Warmerdam, Jelle Wesseling, Marie-Jeanne T Vrancken Peeters, Sabine C Linn, Gabe S Sonke, Dutch Breast Cancer Research Group (BOOG)  

The Lancet Oncology: Volume 19, issue 12, P1630-1640, December 01, 2018

In view of the high proportion of pathological complete responses recorded in both groups and the fact that febrile neutropenia was more frequent in the anthracycline group, omitting anthracyclines from neoadjuvant treatment regimens might be a preferred approach in the presence of dual HER2 blockade in patients with early HER2-positive breast cancer. Long-term follow-up is required to confirm these results.

Breast Implant Mycobacterial Infections: An Epidemiologic Review and Outcome Analysis

Authors:  Al-Halabi, Becher; Viezel-Mathieu, Alex; Shulman, Zachary; Behr, Marcel A.; Fouda Neel, Omar  

Background: Epidemiologic evidence of periprosthetic mycobacterial infections is limited. The recent boom in cosmetic surgery tourism has been associated with a rise of surgical-site infections in returning patients. This review aims to explore available data, examine trends of documented periprosthetic mycobacterial infections, and analyze outcomes of management techniques. Methods: A search in the Biosis, Embase, LILACS, MEDLINE, and Web of Science databases from inception until December of 2017 for “Breast Implants” and “Mycobacterial Infections” and equivalents was performed. Data were pooled after two screening rounds following full-text retrieval and cross-referencing.
Results: Forty-one reports describing 171 female patients who had breast prosthesis–related mycobacterial infections were identified. Bibliometric case-based analysis revealed a rise of periprosthetic mycobacterial infections in developing countries since the start of the millennium. The mean patient’s age was 37.9 years and the majority of patients had undergone bilateral breast augmentation. Most patients presented with breast pain or tenderness, after an average incubation period of 9 months. Mycobacterium fortuitum was isolated from 90 cases (52.6 percent). Immediate explantation with or without delayed reimplantation was the most commonly used surgical strategy, complemented by combination antimicrobial therapy for an average of 4.6 months. The mean follow-up time was 39.7 months, during which recurrence was observed in 21 of 171 patients (12.3 percent).
Conclusions: The emergence of periprosthetic mycobacterial infections in relation to cosmetic medical tourism alerts clinicians to the importance of educating the public about the associated risks. In addition, this study identifies risk factors associated with recurrence of periprosthetic mycobacterial infections.

Thursday, 25 October 2018

Inflammatory breast cancer. A challenging disease with poor prognosis

by Mariam Salim, Hafsa Arif, Osama Shakeel, Amina Iqbal, Huma Majeed, Zulqarnain Chaudhry  

The Breast: October 2018 Volume 41, Supplement 1, Page S22

Introduction: Inflammatory breast cancer (IBC) is an aggressive angioinvasive form of breast cancer associated with a high incidence of early nodal and systemic metastasis. It is a rare cancer in our population, while its incidence is increasing worldwide especially in the United States. It accounts for 1-6% of total breast cancer cases. By its ability to metastasize rapidly, most IBC tumors are characterized as stage IIIB at the time of detection. It is known for aggressive histopathologic features and poor survival.

Can breast cancer metastasize to an unusual organ? : case report and review

by Marija Karakolevska - Ilova  

The Breast: October 2018Volume 41, Supplement 1, Pages S21–S22

Introduction: Metastatic cancer in the thyroid is uncommon and large autopsy studies found out that the incidence of thyroid metastases in patients with a history of cancer ranges from 1.9% to 24%, so in any patient with a previous history of malignancy, a new thyroid mass should be considered as recurrence until proved otherwise. The most frequent primary cancers are renal cell (48.1%), colorectal (10.4%), lung (8.3%) and breast (7.8%) cancers.Most patients with thyroid metastases have widespread metastatic disease but occasionally the thyroid may be the only site of disease with the same impact on prognosis as nonthyroidal metastases.

Physicians attitudes and knowledge about fertility preservation

by M. Lambertini  

The Breast: October 2018Volume 41, Supplement 1, Page S4

In young breast cancer patients diagnosed during their reproductive years, the possible occurrence of treatment-induced premature ovarian insufficiency is of particular concern being associated with important menopause-related symptoms, psychosocial issues as well as infertility. Over the past years, solid evidence has been accumulated to support the management of young patients facing issues related to fertility preservation and specific guidelines have been developed to help physicians in dealing with this topic.

Follow-up clinics: nurses to lead them?

by Y. Wengström  

The Breast: October 2018 Volume 41, Supplement 1, Page S3

Despite substantial evidence that intensive follow up after cancer treatment may not lead to improvements in survival or quality of life, is inefficient at detecting recurrence, and is highly cost ineffective, most patients with cancer are routinely seen in outpatient clinics for many years. The high degree of psychological and functional morbidity among cancer patients suggests a need for close monitoring and support; however, research shows that routine follow up in busy clinics actually provides an environment conducive to supporting patients after a diagnosis of cancer.

Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery

 by Barker, Jenny C.; DiBartola, Kaitlin; Wee, Corinne; Andonian, Nicole; Abdel-Rasoul, Mahmoud; Lowery, Deborah; Janis, Jeffrey E.  

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 443e–450e

Background: The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths attributable to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia is a practice-altering evolution that reduces reliance on opioid medications. Ambulatory breast surgery is an ideal opportunity to implement these strategies.
Methods: A retrospective review of 560 patients undergoing outpatient breast procedures was conducted. Patients received (1) no preoperative analgesia (n = 333); (2) intraoperative intravenous acetaminophen (n = 78); (3) preoperative oral acetaminophen and gabapentin (n = 95); or (4) preoperative oral acetaminophen, gabapentin and celecoxib (n = 54). Outcomes included postanesthesia care unit narcotic use, pain scores, postanesthesia care unit length of stay, rescue antiemetic use, and 30-day complications. Results: Both oral multimodal analgesia regimens significantly reduced postanesthesia care unit narcotic use (oral acetaminophen and gabapentin, 14.3 ± 1.7; oral gabapentin, acetaminophen, and celecoxib, 11.9 ± 2.2; versus no drug, 19.2 ± 1.1 mg oral morphine equivalents; p = 0.0006), initial pain scores (oral acetaminophen and gabapentin, 3.9 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.4 ± 0.7; versus no drug, 5.3 ± 0.3 on a 1 to 10 scale, p = 0.0002) and maximum pain scores (oral acetaminophen and gabapentin, 4.3 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.6 ± 0.7; versus no drug, 5.9 ± 0.3 on a 1 to 10 scale; p < 0.0001). Both oral regimens were better than no medications or intravenous acetaminophen alone in multivariate models after controlling for age, body mass index, American Society of Anesthesiologists class, length of surgery, prior narcotic prescription availability, and intraoperative local anesthetic. Postanesthesia care unit length of stay, antiemetic use, and 30-day complications were not different.
Conclusions: Preoperative oral multimodal analgesia reduces narcotic use and pain scores in outpatient breast plastic surgery. These regimens are inexpensive, improve pain control, and contribute to narcotic-sparing clinical practice in the setting of a national opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

[Review] Opportunities and priorities for breast surgical research

 by Ramsey I Cutress, Stuart A McIntosh, Shelley Potter, Amit Goyal, Cliona C Kirwan, James Harvey, Adele Francis, Amtul R Carmichael, Raghavan Vidya, Jayant S Vaidya, Patricia Fairbrother, John R Benson, Malcolm W R Reed, Association of Breast Surgery Surgical Gap Analysis Working Group  

The Lancet Oncology: Review | vol. 19, issue 10, PE521-E533, October 2018
The 2013 Breast Cancer Campaign gap analysis established breast cancer research priorities without a specific focus on surgical research or the role of surgeons on breast cancer research. This Review aims to identify opportunities and priorities for research in breast surgery to complement the 2013 gap analysis. To identify these goals, research-active breast surgeons met and identified areas for breast surgery research that mapped to the patient pathway. Areas included diagnosis, neoadjuvant treatment, surgery, adjuvant therapy, and attention to special groups (eg, those receiving risk-reducing surgery).

The Functional Influence of Breast Implant Outer Shell Morphology on Bacterial Attachment and Growth

by Jones, Phoebe; Mempin, Maria; Hu, Honghua; Chowdhury, Durdana; Foley, Matthew; Cooter, Rodney; Adams, William P. Jr; Vickery, Karen; Deva, Anand K.  

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 837–849

Background: The introduction of texture to the outer shell of breast implants was aimed at increasing tissue incorporation and reducing capsular contracture. It has also been shown that textured surfaces promote a higher growth of bacteria and are linked to the development of breast implant–associated anaplastic large cell lymphoma.
Methods: The authors aimed to measure the surface area and surface roughness of 11 available implants. In addition, the authors aimed to subject these implant shells to an in vitro bacterial attachment assay with four bacterial pathogens (Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, and Ralstonia pickettii) and study the relationship among surface area, surface roughness, and bacterial growth. Results: Surface area measurement showed grouping of implants into high, intermediate, low, and minimal. Surface roughness showed a correlation with surface area. The in vitro assay showed a significant linear relationship between surface area and bacterial attachment/growth. The high surface area/roughness implant texture grew significantly more bacteria at 24 hours, whereas the minimal surface area/roughness implant textures grew significantly fewer bacteria of all types at 24 hours. For implants with intermediate and low surface areas, some species differences were observed, indicating possible affinity of specific bacterial species to surface morphology.
 Conclusions: Implant shells should be reclassified using surface area/roughness into four categories (high, intermediate, low, and minimal). This classification is superior to the use of descriptive terms such as macrotexture, microtexture, and nanotexture, which are not well correlated with objective measurement and/or functional outcomes.

Wednesday, 19 September 2018

Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

 by Lim, Geok Hoon; Baildam, Andrew D.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 607–610

Background: Risk-reducing mastectomy with tissue expander and then implant-based breast reconstruction conventionally involved immediate submuscular placement of tissue expanders during mastectomy and then, after expansion, replacement of expanders for permanent implants in a second-stage operation. Use of acellular dermal matrix can achieve a single-stage operation; however, acellular dermal matrices are costly and may have potential complications. The authors aim to assess the feasibility of placement of implants as a first-stage procedure before risk-reducing mastectomy as a novel technique of reconstruction that avoids the need for serial outpatient expansion and acellular dermal matrix.
Methods: Patients for whom risk-reducing mastectomy was planned were offered first-stage dual-plane placement of fixed volume silicone gel permanent implants by means of inframammary fold incisions. Risk-reducing mastectomy was undertaken several months later as the second operation, leaving the implants in place protected by the muscle and capsule pocket. Nipples were preserved or reconstructed according to the patient’s choice.
Results: Eight patients with 15 operated breasts were recruited. Anatomically shaped implants were used in all patients, and complete coverage of each implant was achieved. Mean implant volume was 433 ml (range, 290 to 545 ml). There were no complications, and good aesthetic outcomes were achieved.
Conclusions: This proof-of-principle study finds that placement of implants before risk-reducing mastectomy is a novel technique for women at high breast cancer risk that could reduce the use of tissue expanders and acellular dermal matrices and their associated problems. Two-stage risk-reducing mastectomy with first-stage implant placement and subsequent risk-reducing mastectomy leaving the implants in place is feasible, with no complications, and can produce a good cosmetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique

by Sarfati, Benjamin; Struk, Samuel; Leymarie, Nicolas; Honart, Jean-François; Alkhashnam, Heba; Kolb, Frédéric; Rimareix, Françoise  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 624–627

Summary: Robotic nipple-sparing mastectomy could be a significant advancement in the treatment and prophylaxis of selected breast cancers. Motion-scaling, high-resolution, three-dimensional optics; tremor elimination; and instruments with enhanced precision with 7 degrees of freedom have allowed surgeons to overcome the limitations experienced with the endoscopic approach in breast surgery. Advantages of this procedure, in comparison with the open technique, are a shorter and more acceptable scar located in the lateral thoracic region, and greater respect for the vascularization of the mastectomy skin flap, because there is no incision on the breast and no retractors are used. The authors recently received approval from both the French health authorities and the ethics committee to carry out a clinical trial in their institution to assess feasibility, reproducibility, and safety of robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction. The aims of this article are to describe the surgical technique they have developed, and to share, through a video, the clinical experience gained from over 60 procedures performed so far.

Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation

 by Van Slyke, Aaron C.; Carr, Michael; Carr, Nicholas J.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 281e–289e

Background: Augmentation mammaplasty is the most common aesthetic procedure. Textured implants control implant position and have improved capsular contracture rates; however, the impact of texturing on longevity and clinical findings at explantation is unclear.
Methods: All cases of explantation between January of 2005 and April of 2017 from an aesthetic practice were reviewed retrospectively. Patient demographics, implant characteristics, time to explantation, and clinical presentation and intraoperative findings at explantation were analyzed. Results: Five hundred thirty-nine breast implants were explanted during the study period: 249 saline, 147 smooth gel, 123 Biocell, and 20 other nonaggressively textured breast implants. Average time from placement to explantation was 7.5, 5.6, 4.9, and 4.0 years for saline, other textured, smooth gel, and Biocell implants, respectively (p = 3.25e-08). The percentage of implants removed associated with implant performance failure was 50.3, 57.4, 75.0, and 85.4 percent for smooth gel, saline, other textured, and Biocell implants, respectively (p = 7.25e-09). In addition, 21.1 percent of Biocell implants versus 1.4 percent of all other implants presented with pain (p = 2.71e-15). Forty-five Biocell implants had double capsules; this phenomenon was not observed with any other implant type (p = 5.85e-37). Seven Biocell implants had late seromas, compared to three late seromas with any other implant type (p = 0.0013).
Conclusions: Here, the authors provide evidence that Biocell implants have the shortest time to explantation and the highest proportion of implants associated with implant performance failure. This information should complement the informed consent process when selecting an appropriate implant.

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

by Hart, Alexandra M.; Broecker, Justine S.; Kao, Leslieann; Losken, Albert  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 611–620

Background: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery.
Methods: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded.
Results: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication.
Conclusions: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

by Hembd, Austin; Teotia, Sumeet S.; Zhu, Hong; Haddock, Nicholas T.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 583–592

Background: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction.

 Methods: The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions.

Results: Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05).

Conclusions: The authors’ results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.