Monday, 18 September 2017

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions
Merkkola-von Schantzet, P A al
The Breast October 2017 Volume 35, Pages 157–161

Contralateral reduction mammaplasty is regularly included in the treatment of breast cancer patients. We analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens of women with previous breast cancer. We also analyzed if timing of reduction mammaplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics.

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire
Mylvaganam S et al
The Breast October 2017Volume 35, Pages 182–190

The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.

Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer

Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer
Zingarello A et al
The Breast October 2017 Volume 35, Pages 162–168

The rate of local recurrences, after breast-conserving surgery or mastectomy for hormone receptor-positive (HR+) breast cancer, has dramatically changed in last decades, due to advances in surgical and radiation techniques and a more extensive use of adjuvant systemic treatments. However, the occurrence of local recurrences remains a major predictor for distant metastasis and is responsible for increased cancer-specific death. It has been estimated that 1 in 4 HR+ and HR-ipsilateral breast recurrences leads to widespread metastatic disease, with an annual mortality rate of 10% in the first 5 years.

Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review

Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review
Toss M et al
The Breast October 2017 Volume 35, Pages 151–156

The high proportion of ductal carcinoma in situ (DCIS) presented in mammographic screening and the relatively low risk of progression to invasive disease have raised questions related to overtreatment. Following a review of current DCIS management protocols a more conservative approach has been suggested. Clinical trials have been introduced to evaluate the option of avoiding surgical intervention in a proportion of patients with DCIS defined as “low-risk” using certain clinicopathological criteria.

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes
Cohen, O et al

Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 382e–392e

Background: The increasing use of autologous fat grafting in breast cancer patients has raised concerns regarding its oncologic safety. This study evaluated patient outcomes and tumor recurrence following mastectomy reconstruction and autologous fat grafting. 
Methods: Retrospective chart review identified patients who underwent mastectomy followed by breast reconstruction from 2010 to 2015. Eight hundred twenty-nine breasts met inclusion criteria: 248 (30.0 percent) underwent autologous fat grafting, whereas 581 (70.0 percent) breasts did not. Patient demographics, cancer characteristics, oncologic treatment, surgical treatment, surgical complications, local recurrence, and distant metastases were analyzed. 
Results: Autologous fat grafting patients and control patients were of similar body mass index, smoking status, and BRCA status. Patients who underwent fat grafting were significantly younger than control patients and were less likely to have diabetes, hypertension, or hyperlipidemia. The two groups represented similar distributions of BRCA status, Oncotype scores, and hormone receptor status. Patients underwent one to four grafting procedures: one procedure in 83.1 percent, two procedures in 13.7 percent, three in 2.8 percent, and four in 0.4 percent. Mean follow-up time from initial surgery was 45.6 months in the fat grafting group and 38.8 months in controls. The overall complication rate following fat grafting was 9.4 percent. Among breasts undergoing surgery for therapeutic indications, there were similar rates of local recurrence (fat grafting group, 2.5 percent; controls, 1.9 percent; p = 0.747). Interestingly, mean time to recurrence was significantly longer in the fat grafting group (52.3 months versus 22.8 months from initial surgery; p = 0.016). 
Conclusions: Autologous fat grafting is a powerful tool in breast reconstruction. This large, single-institution study provides valuable evidence-based support for its oncologic safety.

Surgical Indications and Outcomes of Mastectomy in Transmen: A Prospective Study of Technical and Self-Reported Measures

Surgical Indications and Outcomes of Mastectomy in Transmen: A Prospective Study of Technical and Self-Reported Measures
van de Grift, T C et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 415e–424e

Background: Although transgender surgery constitutes a growing field within plastic surgery, prospective studies on masculinizing mastectomies are lacking. The objectives of the present study were to prospectively follow a cohort of transmen undergoing mastectomy to assess technical and self-reported outcomes and to evaluate surgical decision-making.
Methods: Fifty-four transmen were recruited during a 10-month period at the Department of Plastic Surgery of the Centre of Expertise on Gender Dysphoria. Preoperative assessment included standardized chest examination. Six months postoperatively, participants rated their satisfaction with surgery, and 12-month postoperative surgical outcomes were reviewed independently. Surgical decision-making was evaluated by comparing indications and outcomes per technique, and assessing the clinical validity of the most-used decision aid (using the Cohen's kappa statistic).
Results: One periareolar mastectomy, 26 concentric circular mastectomies, and 22 inframammary skin resections with free nipple graft were performed in the authors’ cohort. Five participants were still to be operated on. Concentric circular mastectomy was performed in smaller or medium-size breasts with low ptosis grade and good elasticity, whereas the inframammary skin resection group showed a wider range of physical characteristics. Despite being performed in better quality breasts, concentric circular mastectomy was associated with more secondary corrections (38.5 percent), dehiscence, seroma, and lower postoperative satisfaction compared with inframammary skin resections. Clinical decision-making was generally in line with the published decision aid. Conclusions: Compared with inframammary skin resections, concentric circular mastectomy—despite being performed in favorable breast types—appears to produce poorer technical and self-reported outcomes. Surgical indications and preoperative counseling regarding secondary corrections may therefore be subject to improvement.

Autologous Fat Grafting as a Novel Antiestrogen Vehicle for the Treatment of Breast Cancer

Autologous Fat Grafting as a Novel Antiestrogen Vehicle for the Treatment of Breast Cancer
Thomas, S et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 537–544
Background: Adipose fat transfer is increasingly used for contour corrections of the tumor bed after lumpectomy and breast reconstructions after mastectomy. The lipophilic nature of the fat tissue may render adipocytes an ideal vehicle with which to deliver a high boost of an antiestrogen to the tumor bed to serve as an adjunct systemic hormonal therapy. The authors therefore tested whether adipocytes could safely be loaded with an antiestrogen and allow for release at therapeutic concentrations to treat breast cancer. 
Methods: Adipose tissue was collected from patients undergoing autologous fat grafting. The influence of adipose tissue on tumorigenesis was determined both in vitro and in vivo using breast cancer cell lines. Ex vivo, adipose tissue was assessed for its ability to depot fulvestrant and inhibit the growth of breast cancer cell lines. 
Results: Adipose tissue harvested from patients did not promote breast cancer cell growth in vitro or in an in vivo mouse model. Adipose tissue was successfully loaded with fulvestrant and released at levels sufficient to inhibit estrogen receptor signaling and growth of breast cancer cells. 
Conclusions: This work supports the hypothesis that adipose tissue used for autologous fat grafting can serve as a novel method for local drug delivery. As this technique is used to reconstruct a variety of postsurgical defects following cancer resection, this approach for local drug delivery may be an effective alternative in therapeutic settings beyond breast cancer.

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?
Gunnarsson, G L et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 449–454

Background: Nipple-sparing mastectomy with simultaneous hammock technique direct-to-implant reconstruction is increasingly offered to patients opting for risk-reducing mastectomy. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat satisfactorily and more often end up undergoing a difficult corrective procedure and experience an unacceptably high rate of failed reconstruction. The authors examined whether targeted preshaping mastopexy/reduction could prepare these patients for a successful nipple-sparing mastectomy/direct-to-implant reconstruction. 
Methods: Patients seeking risk-reducing nipple-sparing mastectomy/direct-to-implant reconstruction at the authors’ institutions deemed unfit for a one-stage procedure based on their previous experience were offered a targeted two-stage, risk-reducing mastopexy/reduction followed by a delayed secondary nipple-sparing mastectomy and direct-to-implant reconstruction. Patients were followed up at 3 weeks and 6 or 12 months. 
Results: Forty-four reconstructions were performed in 22 patients aged 43 years (range, 26 to 57 years). All 44 procedures were completed successfully without any failure or nipple-areola complex losses. Patients’ median body mass index was 30 kg/m2 (range, 22 to 44 kg/m2). Six patients were smokers and one had hypertension. Two patients underwent reoperation because of hematoma and fat necrosis. 
Conclusions: The authors’ results demonstrate that a targeted preshaping mastopexy/reduction followed by nipple-sparing mastectomy/direct-to-implant reconstruction can be safely planned in women who opt for a risk-reducing mastectomy and can be performed successfully with a 3- to 4-month time span between operations. On the basis of these results and the superior cosmetic outcome, the two-stage approach has become the authors' standard of care in all such settings. 

Macrotextured Breast Implants with Defined Steps to Minimize Bacterial Contamination around the Device: Experience in 42,000 Implants

Macrotextured Breast Implants with Defined Steps to Minimize Bacterial Contamination around the Device: Experience in 42,000 Implants
Adams, W P et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 427–431

Background: Bacteria/biofilm on breast implant surfaces has been implicated in capsular contracture and breast implant–associated anaplastic large-cell lymphoma (ALCL). Macrotextured breast implants have been shown to harbor more bacteria than smooth or microtextured implants. Recent reports also suggest that macrotextured implants are associated with a significantly higher incidence of breast implant–associated ALCL. Using techniques to reduce the number of bacteria around implants, specifically, the 14-point plan, has successfully minimized the occurrence of capsular contracture. The authors hypothesize that a similar effect may be seen in reducing the risk of breast implant–associated ALCL. 
Methods: Pooled data from eight plastic surgeons assessed the use of macrotextured breast implants (Biocell and polyurethane) and known cases of breast implant–associated ALCL. Surgeon adherence to the 14-point plan was also analyzed. 
Results: A total of 42,035 Biocell implants were placed in 21,650 patients; mean follow-up was 11.7 years (range, 1 to 14 years). A total of 704 polyurethane implants were used, with a mean follow-up of 8.0 years (range, 1 to 20 years). The overall capsular contracture rate was 2.2 percent. There were no cases of implant–associated ALCL. All surgeons routinely performed all 13 perioperative components of the 14-point plan; two surgeons do not routinely prescribe prophylaxis for subsequent unrelated procedures. 
Conclusions: Mounting evidence implicates the role of a sustained T-cell response to implant bacteria/biofilm in the development of breast implant–associated ALCL. Using the principles of the 14-point plan to minimize bacterial load at the time of surgery, the development and subsequent sequelae of capsular contracture and breast implant–associated ALCL may be reduced, especially with higher-risk macrotextured implants. 

Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy

Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy
Sbitany, H et al

Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 432–443

Background: Nipple-sparing mastectomy with immediate prosthetic reconstruction is routinely performed because of excellent aesthetic results and safe oncologic outcomes. Typically, subpectoral expanders are placed, but in select patients, this can lead to significant postoperative pain and animation deformity, caused by pectoralis major muscle disinsertion and stretch. Prepectoral reconstruction is a technique that eliminates dissection of the pectoralis major by placing the prosthesis completely above the muscle with complete acellular dermal matrix coverage. 
Methods: A single surgeon’s experience with immediate prosthetic reconstruction following nipple-sparing mastectomy from 2012 to 2016 was reviewed. Patient demographics, adjuvant treatment, length and characteristics of the expansion, and incidence of complications during the tissue expander stage were compared between the partial submuscular/partial acellular dermal matrix (dual-plane) cohort and the prepectoral cohort. 
Results: Fifty-one patients (84 breasts) underwent immediate prepectoral tissue expander placement, compared with 115 patients (186 breasts) undergoing immediate partial submuscular expander placement. The groups had similar comorbidities and postoperative radiation exposure. There was no significant difference in overall complication rate between the two groups (17.9 percent versus 18.8 percent; p = 0.49). 
Conclusions: Prepectoral breast reconstruction provides a safe and effective alternative to partial submuscular reconstruction, that yields comparable aesthetic results with less operative morbidity. In the authors’ experience, the incidence of acute and chronic postoperative pain and animation deformity is significantly lower following prepectoral breast reconstruction. This technique is now considered for all patients who are safe oncologic candidates and are undergoing nipple-sparing mastectomy and prosthetic reconstruction. 

Thursday, 3 August 2017

Oncoplastic breast surgery: comprehensive review.

Oncoplastic breast surgery: comprehensive review.


Bertozzi, N et al

European review for medical and pharmacological sciences; Jun 2017; vol. 21 (no. 11); p. 2572-2585

Breast cancer is the most common female cancer in Western populations, affecting 12.5% of women, with 1.38 million patients per year. Breast-conserving surgery followed by postoperative radiotherapy replaced the radical and modified-radical procedures of Halsted and Patey as the standard of care for early-stage breast cancer once the overall and disease-free survival rates of breast-conserving surgery were demonstrated to be equivalent to those of mastectomy. However, excision of >20% of breast tissue, low or centrally located cancer, and large-sized breasts with various grades of breast ptosis, result a in unacceptable cosmetic outcomes. Oncoplastic breast surgery evolved from the breast-conserving surgery by broadening its general indication to achieve wider excision margins without compromising on the cosmetic outcomes....

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement

Mitchell, SD

Breast cancer research and treatment; Jun 2017

PURPOSE To develop an atlas for oncoplastic surgery (OPS) with template dissection techniques via anatomically ideal incisions for breast conservation surgery. The evolution of breast conservation techniques has evolved from placing an incision directly over the lesion to the incorporation of a thoughtful decision making process utilizing oncoplastic surgical (OPS) techniques to combining OPS with incision placement in anatomically advantageous sites. The high survival rates of breast cancer and effect of breast surgery on quality of life reinforce emphasis of optimal oncologic as well as aesthetic outcome. OPS results in greater patient satisfaction, fewer surgeries, and is oncologically safe. Today's breast surgeon is tasked with optimizing both oncologic and aesthetic outcomes.METHODSPresentation of reproducible dissection techniques and incision placement strategies to afford surgeons a step-by-step approach of OPS via anatomically ideal incisions in breast conservation surgery.RESULTSDemonstration of reproducible techniques to facilitate the decision making process of optimal breast conservation surgery, eliminate knowledge gaps for surgeons, optimize outcome for individuals undergoing breast conservation surgery, and decrease disparity of care.CONCLUSIONAdoption of OPS techniques utilizing an anatomically ideal incision in breast conservation surgery is a feasible and reproducible practice for breast surgeons. Application of these techniques results in maintained optimal shape, size, and contour without the typical overlying skin envelope scars. OPS techniques performed under the skin envelope result in expected OPS oncologic and aesthetic outcomes with the addition of the resulting scar(s) in anatomically discrete position(s).

Evidence-Based Medicine: Alloplastic Breast Reconstruction

Evidence-Based Medicine: Alloplastic Breast Reconstruction

Lennox, PA et al
Plastic & Reconstructive Surgery: July 2017 - Volume 140 - Issue 1 - p 94e–108e


Learning Objectives: After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction. 
Summary: There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. 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.

Tumor-to-Nipple Distance as a Predictor of Nipple Involvement: Expanding the Inclusion Criteria for Nipple-Sparing Mastectomy

Tumor-to-Nipple Distance as a Predictor of Nipple Involvement: Expanding the Inclusion Criteria for Nipple-Sparing Mastectomy

Dent, BL et al
Plastic & Reconstructive Surgery: July 2017 - Volume 140 - Issue 1 - p 1e–8e

Background: A tumor-to-nipple distance of greater than 2 cm has traditionally been considered a criterion for nipple-sparing mastectomy. This study evaluates whether magnetic resonance imaging and sonographic measurements of tumor-to-nipple distance accurately reflect the risk of nipple involvement by disease. 
Methods: All nipple-sparing mastectomy cases with implant-based reconstruction performed by the senior author between July 2006 and December 2014 were retrospectively reviewed. Therapeutic cases with preoperative magnetic resonance imaging or sonography were included. Results: One hundred ninety-five cases were included. Preoperative imaging consisted of sonography (n = 169), magnetic resonance imaging (n = 152), or both (n = 126). With sonography, nipple involvement did not differ between nipple-sparing mastectomy candidates and noncandidates using a tumor-to-nipple distance cutoff of 2 cm (10.7 percent versus 10.6 percent; p = 0.988) or 1 cm (9.3 percent versus 15.0 percent; p = 0.307). With magnetic resonance imaging, nipple involvement did not differ between candidates and noncandidates using a cutoff of 2 cm (11.6 percent versus 12.5 percent; p = 0.881) or 1 cm (11.4 percent versus 13.8 percent; p = 0.718). When sonography and magnetic resonance imaging findings were both available and concordant, nipple involvement still did not differ between candidates and noncandidates using a cutoff of 2 cm (8.8 percent versus 11.8 percent; p = 0.711) or 1 cm (7.6 percent versus 14.3 percent; p = 0.535). 
Conclusion: A tumor-to-nipple distance as small as 1 cm, as measured by sonography or magnetic resonance imaging, should not be considered a contraindication to nipple-sparing mastectomy. 

Current standards in oncoplastic breast conserving surgery

Current standards in oncoplastic breast conserving surgery

Weber, WP et al
The Breast : Article in Press

Oncoplastic breast conserving surgery is increasingly used to treat patients with breast cancer. In the absence of randomized data, a large body of observational evidence consistently indicates low rates of recurrence and high rates of survival, but points to a higher rate of complications compared to conventional breast conserving surgery. Established goals of oncoplastic breast conserving surgery are to broaden the indication for breast conservation towards larger tumors, and to improve esthetic outcomes.

Tuesday, 4 July 2017

Rationale for immunological approaches to breast cancer therapy

Rationale for immunological approaches to breast cancer therapy

Monnot GC and Romero P
The Breast 
Article in Press

Despite great advances in early detection, as well as surgical resection of breast tumours, breast cancer remains the deadliest cancer for women worldwide. Moreover, its incidence is without pair, accounting for twice as many new cancer cases as the second most prevalent cancer, colorectal carcinoma. There is therefore a strong need for new therapeutic approaches to breast cancers. Immunotherapies are novel treatment modalities which aim to use immune mediators to attack cancerous cells. Recent clinical results show that these may not only mediate tumour regressions but also cures in some cases.

Evaluation of margins in invasive carcinoma and ductal carcinoma in situ: The pathologist's perspective

Evaluation of margins in invasive carcinoma and ductal carcinoma in situ: The pathologist's perspective

Schnitt SJ
The Breast 
Article in Press

A variety of patient factors, treatment factors and pathologic factors are associated with an increased risk of ipsilateral breast tumor recurrence (local recurrence) after breast conservation therapy for invasive breast cancer and ductal carcinoma in situ (DCIS). Arguably, the most important of these is the status of the microscopic margins of excision of the resected breast specimen. Until recently there has been no agreement on what constitutes an adequate negative lumpectomy margin for patients with either invasive breast cancer or DCIS managed with the breast conserving approach  and this issue has never been addressed in randomized clinical trials.

Postoperative radiotherapy after DCIS: Useful for whom?

Postoperative radiotherapy after DCIS: Useful for whom?

Karlsson P
The Breast 
Article in Press

The number of patients with ductal carcinoma in situ (DCIS) increases with more widely used screening mammography programs. DCIS accounts for approximately 20% of all new breast cancer diagnoses in these programs and the natural course of this heterogeneous group of pre-invasive lesions is not fully known. Better definition of subgroups benefitting from radiotherapy and knowledge on the natural course of DCIS are important issues for the future management of DCIS.Four large randomized trials have studied the effects of postoperative radiotherapy after breast conserving surgery in patients with wider spectrum of DCIS and all of them have shown radiotherapy to halve the risk of ipsilateral events, however, without any significant effect on breast cancer mortality.

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction

Muresan, H et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1232e–1239e

Background: Patients undergoing implant-based reconstruction in the setting of postmastectomy radiation therapy suffer from increased complications and inferior outcomes compared with those not irradiated, but advances in radiation delivery have allowed for more nuanced therapy. The authors investigated whether these advances impact patient outcomes in implant-based breast reconstruction. 
Methods: Retrospective chart review identified all implant-based reconstructions performed at a single institution from November of 2010 to November of 2013. These data were cross-referenced with a registry of patients undergoing breast irradiation. Patient demographics, treatment characteristics, and outcomes were analyzed. 
Results: Three hundred twenty-six patients (533 reconstructions) were not irradiated, whereas 83 patients (125 reconstructions) received radiation therapy; mean follow-up was 24.7 months versus 26.0 months (p = 0.49). Overall complication rates were higher in the irradiated group (35.2 percent versus 14.4 percent; p < 0.01). Increased maximum radiation doses to the skin were associated with complications (maximum dose to skin, p = 0.05; maximum dose to 1 cc of skin, p = 0.01). Different treatment modalities (e.g., three-dimensional conformal, intensity-modulated, field-in-field, and hybrid techniques) did not impact complication rates. Prone versus supine positioning significantly decreased the maximum skin dose (58.5 Gy versus 61.7 Gy; p = 0.05), although this did not translate to significantly decreased complication rates in analysis of prone versus supine positioning. 
Conclusions: As radiation techniques evolve, the maximum dose to skin should be given consideration similar to that for heart and lung dosing, to optimize reconstructive outcomes. Prone positioning significantly decreases the maximum skin dose and trends toward significance in reducing reconstructive complications. With continued study, this may become clinically important. Interdepartmental studies such as this one ensure quality of care.

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Aliu, O et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1224e–1231e

Background: In the debate on reconstruction of the irradiated breast, there is little information on associated health care resource use. Nationwide data were used to examine health care resource use associated with implant and autologous reconstruction. It was hypothesized that failure rates would contribute the most to higher average cumulative cost with either reconstruction method. 
Methods: From the 2009 to 2013 MarketScan Commercial Claims and Encounters database, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected. In a 24-month follow-up period, the cumulative costs of health care services used were tallied and described. Regression models stratified by reconstruction method were then used to estimate the influence of failure on cumulative cost of reconstruction. 
Results: There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively. Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases. Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction. The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344. In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for autologous reconstruction. 
Conclusions: More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure. These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.