Tuesday, 21 March 2017

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model

Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model
Dumestre, D et al 
Plastic & Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 550–559

Background: Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction. 
Methods: Length of stay, emergency room visits, and complications within 30 days of surgery were compared among three groups: traditional recovery after surgery, transition (some elements of enhanced recovery protocol, not transitioned to outpatient care), and enhanced recovery after surgery (day surgery, provided with standardized perioperative education and multimodal analgesia). Prospective data collection allowed quality-of-recovery assessment using a validated questionnaire for enhanced recovery/transition groups. Results were statistically analyzed (analysis of variance/chi-square). 
Results: The traditional recovery, transition, and enhanced recovery cohorts comprised 29, 11, and 29 patients, respectively. No significant differences were present regarding age, smoking status, preoperative radiation, single stage direct-to-implant versus tissue expander, bilateral versus unilateral surgery, or immediate versus delayed reconstruction among groups. Average length of stay was 1.6 nights in both the traditional recovery and transition groups, compared with 0 nights in the enhanced recovery group (p < 0.001). Enhanced recovery patients had less severe pain (p = 0.02) and nausea (p = 0.01), and better enjoyed their food (p = 0.0002) and felt more rested (p = 0.02) than their transition counterparts. There were no differences in the number of emergency room visits among the three groups (p = 0.88). There was no difference in the rate of hematoma (p = 0.36), infection requiring intravenous antibiotics (p = 0.36), or infection requiring explantation (p = 0.36) among the three groups. Conclusion: An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely, with improved patient satisfaction and same-day discharge and with no increase in complications. 

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation: A Randomized Controlled Trial

Intraoperative Comparison of Anatomical versus Round Implants in Breast Augmentation: A Randomized Controlled Trial
Hidalgo, DA. Weinstein, AL. 
Plastic & Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 587–596

Background: The purpose of this randomized controlled trial was to determine whether anatomical implants are aesthetically superior to round implants in breast augmentation. 
Methods: Seventy-five patients undergoing primary breast augmentation had a round silicone implant of optimal volume, projection, and diameter placed in one breast and an anatomical silicone device of similar volume and optimal shape placed in the other. After intraoperative photographs were taken, the anatomical device was replaced by a round implant to complete the procedure. A survey designed to measure breast aesthetics was administered to 10 plastic surgeon and 10 lay reviewers for blind evaluation of the 75 cases. 
Results: No observable difference in breast aesthetics between anatomical and round implants was reported by plastic surgeons in 43.6 percent or by lay individuals in 29.2 percent of cases. When a difference was perceived, neither plastic surgeons nor lay individuals preferred the anatomical side more often than the round side. Plastic surgeons judged the anatomical side superior in 51.1 percent of cases and the round side superior in 48.9 percent of cases (p = 0.496). Lay individuals judged the anatomical side superior in 46.7 percent of cases and the round side superior in 53.3 percent (p = 0.140). Plastic surgeons identified implant shape correctly in only 26.5 percent of cases. Conclusions: This study provides high-level evidence supporting no aesthetic superiority of anatomical over round implants. Given that anatomical implants have important and unique disadvantages, a lack of proven aesthetic superiority argues against their continued use in breast augmentation.

Comparison of Different Acellular Dermal Matrices in Breast Reconstruction: The 50/50 Study

Comparison of Different Acellular Dermal Matrices in Breast Reconstruction: The 50/50 Study
Pittman, T et al
Plastic & Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 521–528

Background: Acellular dermal matrix has enjoyed extensive use in primary and secondary alloplastic breast aesthetic and reconstructive surgery. The objective of this study was to examine clinical outcomes between available acellular dermal matrix products: DermACELL (LifeNet Health, Virginia Beach, Va.) and AlloDerm Ready To Use (LifeCell Corp., Branchburg, N.J.). 
Methods: A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL (n = 30 patients; 50 breasts) or AlloDerm Ready To Use (n = 28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same plastic surgeon (T.A.P.). Statistical analysis was performed by means of Fisher’s exact test. 
Results: Differences in the average age, body mass index, percentage having neoadjuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups were not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days after immediate reconstruction. When comparing outcomes, patients in the DermACELL group had a significantly lower incidence of “red breast syndrome” (0 percent versus 26 percent; p = 0.0001) and fewer days before drain removal (15.8 days versus 20.6 days; p = 0.017). No significant differences were seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, or explantation. 
Conclusion: Patients reconstructed with DermACELL as compared with AlloDerm Ready To Use have significantly decreased number of days to drain removal and red breast syndrome and equivalent rates of other complications, including seroma, infection, flap necrosis, and explantation. 

Feasibility of magnetic marker localisation for non-palpable breast cancer

Feasibility of magnetic marker localisation for non-palpable breast cancer
Schermers B et al
The Breast, June 2017Volume 33, Pages 50–56

Accurate tumour localisation is essential for breast-conserving surgery of non-palpable tumours. Current localisation technologies are associated with disadvantages such as logistical challenges and migration issues (wire guided localisation) or legislative complexities and high administrative burden (radioactive localisation). We present MAgnetic MArker LOCalisation (MaMaLoc), a novel technology that aims to overcome these disadvantages using a magnetic marker and a magnetic detection probe. This feasibility study reports on the first experience with this new technology for breast cancer localisation.

Axillary reverse mapping in N0 patients requiring sentinel lymph node biopsy – A systematic review of the literature and necessity of a randomised study

Axillary reverse mapping in N0 patients requiring sentinel lymph node biopsy – A systematic review of the literature and necessity of a randomised study
Parks RM, Cheung KL
The Breast, June 2017 Volume 33, Pages 57–70

Axillary reverse mapping (ARM) is a technique to map and preserve arm lymphatics which may be damaged during surgery, resulting in lymphoedema.This work systematically reviews the incidence of lymphoedema following sentinel lymph node biopsy (SLNB) + ARM, compared to SLNB alone, for clinically node negative disease, as well as recurrence rate, other morbidity and the feasibility and difficulties of ARM.

Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer

Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer
Cakmaket KG al
The Breast, June 2017Volume 33, Pages 23–28

Intraoperative ultrasound guided (IUG) breast conserving surgery (BCS) is being increasingly embraced by breast surgeons worldwide. We aimed to compare the efficacy of IUG-BCS for palpable and nonpalpable breast cancer with respect to margin status, re-excision rate, tissue sacrifice and cost-time analysis.

Multidetector CT improving surgical outcomes in breast cancer (MISO-BC): A randomised controlled trial

Multidetector CT improving surgical outcomes in breast cancer (MISO-BC): A randomised controlled trial
Cox J et al
The Breast, April 2017 Volume 32, Pages 217–224

CT scan-guided care did not result in a change in the number of patients requiring a second operation; similar numbers of patients needed further axillary surgery in both groups. New diagnostic imaging technologies regularly enter NHS centres. It is important these are evaluated rigorously before becoming routine care.

Cost-effectiveness of risk-reducing surgeries in preventing hereditary breast and ovarian cancer

Cost-effectiveness of risk-reducing surgeries in preventing hereditary breast and ovarian cancer
Schrauder MG et al
The Breast, April 2017Volume 32, Pages 186–191

Risk-reducing surgeries are a feasible option for mitigating the risk in individuals with inherited susceptibility to cancer, but are the procedures cost-effective in the current health-care system in Germany? This study compared the health-care costs for bilateral risk-reducing mastectomy (BRRM) and risk-reducing (bilateral) salpingo-oophorectomy (RRSO) with cancer treatment costs that could potentially be prevented.

Wednesday, 22 February 2017

Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results

Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results
Sigalove, S et al
Plastic & Reconstructive Surgery:February 2017 - Volume 139 - Issue 2 - p 287–294

Summary: Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions. 

Outcome Evaluation after 2023 Nipple-Sparing Mastectomies: Our Experience

Outcome Evaluation after 2023 Nipple-Sparing Mastectomies: Our Experience
De Vita, R et al
Plastic & Reconstructive Surgery:February 2017 - Volume 139 - Issue 2 - p 335e–347e


Background: Although quadrantectomy and lumpectomy help diminish the psychological and physical devastation inflicted, mastectomy is still elected in 20 to 30 percent of breast cancers. Although initially inciting controversy over heightened risk of local recurrences, recent studies maintain that nipple-sparing mastectomy can be used in any patient qualifying for total mastectomy and also improves aesthetic and psychologic outcomes. The manner in which mastectomy influences reconstructive implant outcomes has been documented by several groups. This report details the authors’ experience performing nipple-sparing mastectomy with immediate implant-based breast reconstruction, focusing attention on patient characteristics and aspects of surgical mastectomy that influence reconstruction outcomes. The aim of the study was to examine various issues, such as surgical access, mode of tissue dissection, and flap thickness, clearly linked to development of complications and poor results. Methods: A retrospective study was conducted, analyzing patients with breast cancer. An external three-surgeon panel served to generate average scores for predefined parameters. Based on total scores, outcomes were designated excellent, good, moderate, or poor. Results: The authors’ cohort included 1647 patients. Overall, 2023 nipple-sparing mastectomies were performed, including bilateral procedures in 376 patients. After a minimum follow-up period of 12 months, the authors’ cohort was stratified by scored outcomes. Significant impact of body mass index, skin incision, flap thickness, and grade of ptosis has been demonstrated. Conclusions: The authors’ data suggest that proper patient selection and well-executed operations are mandatory to limit complications. They also indicate that aesthetic outcome is clearly dependent on surgical proficiency and some patient characteristics. 

Impact of selective use of breast MRI on surgical decision-making in women with newly diagnosed operable breast cancer

Impact of selective use of breast MRI on surgical decision-making in women with newly diagnosed operable breast cancer
Brennan, Meagan E. et al.
The Breast , Volume 32 , 135 - 143

This study evaluated the impact of breast MRI on surgical planning in selected cases of breast malignancy (invasive cancer or DCIS). MRI was used when there was ambiguity on clinical and/or conventional imaging assessment.

An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation

An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation
Barnea, Y et al
Plastic & Reconstructive Surgery:February 2017 - Volume 139 - Issue 2 - p 348e–357e

Background: Patients with a small breast volume and a relative large lumpectomy volume are at risk of developing severe breast deformity and asymmetry following breast conservation, presenting a unique surgical challenge. Methods: A series of patients undergoing immediate reconstruction by means of an oncoplastic breast augmentation technique following breast conservation are described. The technique includes local tissue rearrangement and bilateral subpectoral breast augmentation with implants of different sizes and shapes, immediately after lumpectomy for a malignant tumor. Results: Twenty-one consecutive patients underwent the oncoplastic breast augmentation technique (mean follow-up, 23 months; range, 12 to 48 months). Three patients (14.3 percent) had tumor-positive surgical margins. Postoperative complications included grade III/IV capsular contracture in five patients (23.8 percent) and breast infection in two patients (10 percent). All patients received postoperative radiation therapy. The cosmetic outcome was evaluated at least 6 months after radiation therapy, and it was favorable according to the reported high patient satisfaction (81 percent) and independent observers’ evaluation scores (76 percent). Conclusions: The oncoplastic breast augmentation technique described in this article is an acceptable option in small-breasted patients with a relatively large lumpectomy volume who elect to undergo breast conservation. This technique allows conservation of the affected breast and minimizes potential breast deformation and asymmetry following radiation therapy.

The Evolution of Surgical Simulation: The Current State and Future Avenues for Plastic Surgery Education

The Evolution of Surgical Simulation: The Current State and Future Avenues for Plastic Surgery Education
Kazan, R et al
Plastic & Reconstructive Surgery:February 2017 - Volume 139 - Issue 2 - p 533e–543e

Summary: Alongside the ongoing evolution of surgical training toward a competency-based paradigm has come the need to reevaluate the role of surgical simulation in residency. Simulators offer the ability for trainees to acquire specific skills and for educators to objectively assess the progressive development of these skills. In this article, the authors discuss the historical evolution of surgical simulation, with a particular focus on its past and present role in plastic surgery education. The authors also discuss the future steps required to further advance plastic surgery simulation in an effort to continue to train highly competent plastic surgery graduates.

Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study

Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study
Metcalfe, K A.et al
Plastic & Reconstructive Surgery: February 2017 - Volume 139 - Issue 2 - p 267–275

Background: Delayed breast reconstruction is an option for women who have undergone mastectomy; however, uptake is low. The purpose of this study was to identify premastectomy and postmastectomy demographic, clinical, and psychosocial predictors of uptake of delayed breast reconstruction in the long-term survivorship period. 
Methods: This was a prospective longitudinal survey study of mastectomy patients in which a repeated measures design was used to evaluate uptake of delayed breast reconstruction. Demographic, clinical, and psychosocial variables were collected before mastectomy and 1 year after mastectomy. Information regarding uptake of delayed breast reconstruction was collected at approximately 6 years after mastectomy. A predictive model was designed using a multivariate logistic regression model and Akiake information criterion stepwise algorithm. 
Results: Ninety-six mastectomy patients were followed from before mastectomy to 75.2 months after mastectomy, and 35 women (36.5 percent) underwent delayed breast reconstruction. Women who elected for delayed breast reconstruction experienced worsening of body concerns from before mastectomy to 1 year after mastectomy, compared with women who did not elect to undergo delayed breast reconstruction (p = 0.03). Mean scores for psychological distress were significantly worse both before mastectomy and 1 year after mastectomy in women who went on to undergo delayed breast reconstruction compared with those who did not undergo delayed breast reconstruction (p = 0.034 and p = 0.022, respectively). A predictive model for the uptake of delayed breast reconstruction was developed using demographic, clinical, and psychosocial characteristics. The area under the receiver operating characteristic curve was 85 percent, indicating good precision. Conclusions: Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select delayed breast reconstruction. This may have implications for postreconstruction satisfaction and psychosocial functioning.

An exploration of Australian psychologists' role in assessing women considering risk-reducing or contralateral prophylactic mastectomy

An exploration of Australian psychologists' role in assessing women considering risk-reducing or contralateral prophylactic mastectomy
Braude, Lucy et al.
The Breast , Volume 32 , 105 - 111

Given increasing rates of risk-reducing mastectomies (RRM) and contralateral prophylactic mastectomies (CPM), and the potentially significant psychological sequelae of this irreversible procedure, health professionals (HPs) regularly refer patients to psychologists for pre-operative assessment and support. This is the first study to provide qualitative insights from HPs into the role of psychologists who are working with women considering RRM or CPM.

Evidence-Based Medicine: Autologous Breast Reconstruction

Evidence-Based Medicine: Autologous Breast Reconstruction
Macadam, SA et al
Plastic & Reconstructive Surgery:January 2017 - Volume 139 - Issue 1 - p 204e–229e

Learning Objectives: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. Summary: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Tuesday, 17 January 2017

Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey

Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey

The Breast: April 2017Volume 32, Pages 60–65
Coroneos CJ et al

The purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication.

Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: Comparison between immunohistochemical subtypes

Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: Comparison between immunohistochemical subtypes
The Breast: April 2017Volume 32, Pages 37–43
Barrou J et al

Even if neoadjuvant chemotherapy (NACT) and oncoplastic techniques have increased the breast conserving surgery rate, mastectomy is still a standard for multifocal or extensive breast cancers (BC). In the prospect of increasing breast reconstruction, an alternative therapeutic protocol was developed combining NACT with neoadjuvant radiation therapy (NART), followed by mastectomy with immediate breast reconstruction (IBR). The oncological safety of this therapeutic plan still needs further exploration.

Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes

Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes
The Breast: April 2017Volume 32, Pages 7–12
Ilonzo N et al

The landscape of breast reconstruction has changed significantly. This study assesses trends in type of reconstruction performed after mastectomy and impact on immediate postoperative complications.

Reducing implant loss rates in immediate breast reconstructions

Reducing implant loss rates in immediate breast reconstructions
The Breast: February 2017Volume 31, Pages 208–213
Darragh L et al

UK best practice guidelines for oncoplastic breast reconstruction were published in 2012. Implant-based reconstruction quality indicator (QI) targets for readmission, return to theatre and implant loss rates were set at 5% by 3 months, along with guidance to achieve these targets. The aims of this study were to quantify complication rates following implant-based reconstruction before and after the implementation of the guidelines. A retrospective audit of 86 patients with 106 implants in the 12 months to June 2013 was performed, C1.