Management of Women Who Have a Genetic Predisposition for Breast Cancer
Ismail Jatoi, William F. Anderson
pages 845-861
Friday, 22 August 2008
Plastic and reconstructive surgery Jun and Jul 2008
An innovative three-dimensional approach to defining the anatomical changes occurring after short scar-medial pedicle reduction mammaplasty.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 1875-85
Tepper-Oren-M, Choi-Mihye, Small-Kevin, Unger-Jacob et al
Abstract
BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three- dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three- dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively; p <>
Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 315-6
Munhoz-Alexandre-Mendonca.
Comment, Letter.
Comment on: Plast Reconstr Surg. 2007 Dec; 120(7):1769-73.
Salvage of a congested DIEP flap: a new technique.
Plastic and reconstructive surgery Jul 2008, vol. 122, no. 1
p. 41e-42e
Shamsian-Negin, Sassoon-Elaine, Haywood-Richard.
Utility and anatomical examination of the DIEP flap's three- dimensional image with multidetector computed tomography.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 40e-41e
Mihara-Makoto, Nakanishi-Misa, Nakashima-Miho, Narushima-Mitunaga, Koshima-Isao.
A local anesthetic pump reduces postoperative pain and narcotic and antiemetic use in breast reconstruction surgery: a randomized controlled trial.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 39-52
Rawlani-Vinay, Kryger-Zol-B, Lu-Leonard, Fine-Neil-A.
Abstract
BACKGROUND: The purpose of this study was to conduct a double-blind, randomized, prospective trial evaluating the efficacy of a local anesthetic pain pump in reducing postoperative pain, narcotic use, and the incidence of postoperative nausea and vomiting in breast reduction surgery. METHODS: Thirty-one patients undergoing bilateral breast reduction using a single technique (inferior pedicle, Wise pattern with supplemental liposuction) were enrolled. The patients were randomized to receive either 0.25% bupivacaine (n = 16) or 0.9% saline (n = 15) delivered over a period of 48 to 55 hours. All patients were monitored postoperatively and completed a written survey and telephone interview. Parameters measured over a period of 48 hours included subjective pain, episodes of postoperative nausea and vomiting, and the amount of narcotics and antiemetics used. RESULTS: There were no statistically significant differences between the two groups regarding patient age, body mass index, weight of the breast reduction, complication rate, and standardized subjective pain perception. Patients randomized to bupivacaine reported significantly lower pain scores on the day of surgery and on the first and second postoperative days when compared with patients receiving placebo (p <>
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 1875-85
Tepper-Oren-M, Choi-Mihye, Small-Kevin, Unger-Jacob et al
Abstract
BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three- dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three- dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively; p <>
Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 315-6
Munhoz-Alexandre-Mendonca.
Comment, Letter.
Comment on: Plast Reconstr Surg. 2007 Dec; 120(7):1769-73.
Salvage of a congested DIEP flap: a new technique.
Plastic and reconstructive surgery Jul 2008, vol. 122, no. 1
p. 41e-42e
Shamsian-Negin, Sassoon-Elaine, Haywood-Richard.
Utility and anatomical examination of the DIEP flap's three- dimensional image with multidetector computed tomography.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 40e-41e
Mihara-Makoto, Nakanishi-Misa, Nakashima-Miho, Narushima-Mitunaga, Koshima-Isao.
A local anesthetic pump reduces postoperative pain and narcotic and antiemetic use in breast reconstruction surgery: a randomized controlled trial.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 39-52
Rawlani-Vinay, Kryger-Zol-B, Lu-Leonard, Fine-Neil-A.
Abstract
BACKGROUND: The purpose of this study was to conduct a double-blind, randomized, prospective trial evaluating the efficacy of a local anesthetic pain pump in reducing postoperative pain, narcotic use, and the incidence of postoperative nausea and vomiting in breast reduction surgery. METHODS: Thirty-one patients undergoing bilateral breast reduction using a single technique (inferior pedicle, Wise pattern with supplemental liposuction) were enrolled. The patients were randomized to receive either 0.25% bupivacaine (n = 16) or 0.9% saline (n = 15) delivered over a period of 48 to 55 hours. All patients were monitored postoperatively and completed a written survey and telephone interview. Parameters measured over a period of 48 hours included subjective pain, episodes of postoperative nausea and vomiting, and the amount of narcotics and antiemetics used. RESULTS: There were no statistically significant differences between the two groups regarding patient age, body mass index, weight of the breast reduction, complication rate, and standardized subjective pain perception. Patients randomized to bupivacaine reported significantly lower pain scores on the day of surgery and on the first and second postoperative days when compared with patients receiving placebo (p <>
A new preoperative imaging modality for free flaps in breast reconstruction: computed tomographic angiography.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 38e-40e,
Rozen-Warren-M, Phillips-Timoth-J, Ashton-Mark-W, Stella-Damien-L, Taylor-G-Ian.
Sonographic assessment on breast augmentation after autologous fat graft.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1, p. 36e-38e
Wang-Hongyan, Jiang-Yuxin, Meng-Hua, Yu-Yuan, Qi-Keming.
Use of patient body mass index as a rationing tool in breast reduction surgery.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1, p. 35e-36e
Tadiparthi-Sujatha, Liew-S-H.
The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
Rozen-Warren-M, Phillips-Timoth-J, Ashton-Mark-W, Stella-Damien-L, Taylor-G-Ian.
Sonographic assessment on breast augmentation after autologous fat graft.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1, p. 36e-38e
Wang-Hongyan, Jiang-Yuxin, Meng-Hua, Yu-Yuan, Qi-Keming.
Use of patient body mass index as a rationing tool in breast reduction surgery.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1, p. 35e-36e
Tadiparthi-Sujatha, Liew-S-H.
The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 29-38
Schoeller-Thomas, Huemer-Georg-M, Wechselberger-Gottfried.
Abstract
BACKGROUND: The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. METHODS: A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). RESULTS: Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). CONCLUSIONS: The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.
Schoeller-Thomas, Huemer-Georg-M, Wechselberger-Gottfried.
Abstract
BACKGROUND: The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. METHODS: A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). RESULTS: Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). CONCLUSIONS: The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.
True incidence of all complications following immediate and delayed breast reconstruction.
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 19-28
Sullivan-Stephen-R, Fletcher-Derek-R-D, Isom-Casey-D, Isik-F-Frank.
Abstract
BACKGROUND: Improved self-image and psychological well-being after breast reconstruction are well documented. To determine methods that optimized results with minimal morbidity, the authors examined their results and complications based on reconstruction method and timing. METHODS: The authors reviewed all breast reconstructions after mastectomy for breast cancer performed under the supervision of a single surgeon over a 6-year period at a tertiary referral center. Reconstruction method and timing, patient characteristics, and complication rates were reviewed. RESULTS: Reconstruction was performed on 240 consecutive women (94 bilateral and 146 unilateral; 334 total reconstructions). Reconstruction timing was evenly split between immediate (n = 167) and delayed (n = 167). Autologous tissue (n = 192) was more common than tissue expander/implant reconstruction (n = 142), and the free deep inferior epigastric perforator was the most common free flap (n = 124). The authors found no difference in the complication incidence with autologous reconstruction, whether performed immediately or delayed. However, there was a significantly higher complication rate following immediate placement of a tissue expander when compared with delayed reconstruction (p = 0.008). Capsular contracture was a significantly more common late complication following immediate (40.4 percent) versus delayed (17.0 percent) reconstruction
Sullivan-Stephen-R, Fletcher-Derek-R-D, Isom-Casey-D, Isik-F-Frank.
Abstract
BACKGROUND: Improved self-image and psychological well-being after breast reconstruction are well documented. To determine methods that optimized results with minimal morbidity, the authors examined their results and complications based on reconstruction method and timing. METHODS: The authors reviewed all breast reconstructions after mastectomy for breast cancer performed under the supervision of a single surgeon over a 6-year period at a tertiary referral center. Reconstruction method and timing, patient characteristics, and complication rates were reviewed. RESULTS: Reconstruction was performed on 240 consecutive women (94 bilateral and 146 unilateral; 334 total reconstructions). Reconstruction timing was evenly split between immediate (n = 167) and delayed (n = 167). Autologous tissue (n = 192) was more common than tissue expander/implant reconstruction (n = 142), and the free deep inferior epigastric perforator was the most common free flap (n = 124). The authors found no difference in the complication incidence with autologous reconstruction, whether performed immediately or delayed. However, there was a significantly higher complication rate following immediate placement of a tissue expander when compared with delayed reconstruction (p = 0.008). Capsular contracture was a significantly more common late complication following immediate (40.4 percent) versus delayed (17.0 percent) reconstruction
Use of 2-Octyl-Cyanoacrylate Skin Adhesive (Dermabond) for Wound Closure following Reduction Mammaplasty: A Prospective, Randomized Intervention
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 10-8
Nipshagen-Martine-D, Hage-J-Joris, Beekman-Werner-H.
Abstract
BACKGROUND: 2-Octyl-cyanoacrylate skin adhesive may be used for surgical wound closure. However, its use in plastic surgery has not been properly assessed. METHODS: The authors conducted a prospective, randomized, controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared with those after suture closure. Bilateral reduction mammaplasty was performed in 50 patients. The method of closure (sutures versus skin adhesive) applied to each breast was determined randomly, using each patient as her own control. Scars were assessed by the patient and by a blinded panel, at 1 week, 6 weeks, and 6 months after surgery, using a visual analogue scale, the modified Hollander Wound Evaluation Scale, and the Patient and Observer Scar Assessment Scale. RESULTS: Both patients and panelists expressed an overall preference for the adhesive side as of 1 week after surgery. Patients' visual analogue scale scores for scar comfort and scar appearance and panelists' visual analogue scale scores for aesthetic outcome were significantly better for the adhesive side after 6 weeks and 6 months
Nipshagen-Martine-D, Hage-J-Joris, Beekman-Werner-H.
Abstract
BACKGROUND: 2-Octyl-cyanoacrylate skin adhesive may be used for surgical wound closure. However, its use in plastic surgery has not been properly assessed. METHODS: The authors conducted a prospective, randomized, controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared with those after suture closure. Bilateral reduction mammaplasty was performed in 50 patients. The method of closure (sutures versus skin adhesive) applied to each breast was determined randomly, using each patient as her own control. Scars were assessed by the patient and by a blinded panel, at 1 week, 6 weeks, and 6 months after surgery, using a visual analogue scale, the modified Hollander Wound Evaluation Scale, and the Patient and Observer Scar Assessment Scale. RESULTS: Both patients and panelists expressed an overall preference for the adhesive side as of 1 week after surgery. Patients' visual analogue scale scores for scar comfort and scar appearance and panelists' visual analogue scale scores for aesthetic outcome were significantly better for the adhesive side after 6 weeks and 6 months
Prophylactic Mastectomy and Reconstruction: Clinical Outcomes and Patient Satisfaction
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
Plastic and reconstructive surgery, Jul 2008, vol. 122, no. 1
p. 1-9
Spear-Scott-L, Schwarz-Karl-A, Venturi-Mark-L, Barbosa-Todd, Al- Attar-Ali.
Abstract
BACKGROUND: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction. METHODS: A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons. RESULTS: There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again. CONCLUSIONS: Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.
Skin banking in autologous breast reconstruction.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
Spear-Scott-L, Schwarz-Karl-A, Venturi-Mark-L, Barbosa-Todd, Al- Attar-Ali.
Abstract
BACKGROUND: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction. METHODS: A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons. RESULTS: There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again. CONCLUSIONS: Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.
Skin banking in autologous breast reconstruction.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 2177-8; author reply 2178
Kovach-Stephen-J.
Comment, Letter.
Comment on: Plast Reconstr Surg. 2007 Oct; 120(5):1133-6.
The impact of obesity on patient satisfaction with breast reconstruction.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
Kovach-Stephen-J.
Comment, Letter.
Comment on: Plast Reconstr Surg. 2007 Oct; 120(5):1133-6.
The impact of obesity on patient satisfaction with breast reconstruction.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 1893-9
Atisha-Dunya-M, Alderman-Amy-K, Kuhn-Latoya-E, Wilkins-Edwin-G.
Abstract
BACKGROUND: As the U.S. population becomes increasingly overweight, a growing number of patients with body mass indexes greater than 30 are seeking mastectomy reconstruction. The authors' purpose was to prospectively evaluate the effect of body mass index on patient satisfaction with breast reconstruction. METHODS: Women undergoing first-time breast reconstruction at one of 12 centers in the United States and Canada were surveyed preoperatively and at postoperative year 1. Satisfaction was evaluated with two scales assessing general and aesthetic satisfaction. Using Centers for Disease Control and Prevention criteria, patients were classified as normal weight, overweight, or obese. Logistic regressions evaluated the effects of body mass index on patient satisfaction with expander/implant, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap techniques while controlling for patient age and timing of reconstruction. RESULTS: Data were available for a total of 262 patients. Patient body mass index had a significant effect on aesthetic satisfaction, particularly among patients undergoing expander/implant procedures. Compared with normal weight individuals, obese patients with expander/implants were significantly less satisfied aesthetically (odds ratio, 0.14, p = 0.02). However, there was no significant difference between obese and normal weight patients in aesthetic satisfaction with TRAM flap reconstruction. Finally, body mass index had no significant effects on general satisfaction for either expander/implant or TRAM flap technique. CONCLUSION: Although previous investigators have reported relatively high complication rates and modest aesthetic results for breast reconstruction in overweight and obese women, the authors' study suggests that patient satisfaction with reconstruction is surprisingly high in this population, particularly in cases of autogenous tissue reconstruction.
Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
Atisha-Dunya-M, Alderman-Amy-K, Kuhn-Latoya-E, Wilkins-Edwin-G.
Abstract
BACKGROUND: As the U.S. population becomes increasingly overweight, a growing number of patients with body mass indexes greater than 30 are seeking mastectomy reconstruction. The authors' purpose was to prospectively evaluate the effect of body mass index on patient satisfaction with breast reconstruction. METHODS: Women undergoing first-time breast reconstruction at one of 12 centers in the United States and Canada were surveyed preoperatively and at postoperative year 1. Satisfaction was evaluated with two scales assessing general and aesthetic satisfaction. Using Centers for Disease Control and Prevention criteria, patients were classified as normal weight, overweight, or obese. Logistic regressions evaluated the effects of body mass index on patient satisfaction with expander/implant, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap techniques while controlling for patient age and timing of reconstruction. RESULTS: Data were available for a total of 262 patients. Patient body mass index had a significant effect on aesthetic satisfaction, particularly among patients undergoing expander/implant procedures. Compared with normal weight individuals, obese patients with expander/implants were significantly less satisfied aesthetically (odds ratio, 0.14, p = 0.02). However, there was no significant difference between obese and normal weight patients in aesthetic satisfaction with TRAM flap reconstruction. Finally, body mass index had no significant effects on general satisfaction for either expander/implant or TRAM flap technique. CONCLUSION: Although previous investigators have reported relatively high complication rates and modest aesthetic results for breast reconstruction in overweight and obese women, the authors' study suggests that patient satisfaction with reconstruction is surprisingly high in this population, particularly in cases of autogenous tissue reconstruction.
Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk.
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 1886-92
McCarthy-Colleen-M, Mehrara-Babak-J, Riedel-Elyn et al
Abstract
BACKGROUND: Complications following postmastectomy reconstruction can cause significant morbidity. The compound effect of individual risk factors on the development of complications following expander /implant reconstruction has not, however, been well delineated. This study evaluated the impact of clinical risk factors to predict complications following postmastectomy expander/implant reconstruction. METHODS: From 2003 through 2004, 1170 expander /implant reconstructions were performed at a single center. A prospectively maintained database was reviewed. Variables including age, smoking status, body mass index, history of diabetes, hypertension, chemotherapy and/or radiation, as well as timing and laterality of reconstruction were evaluated. The primary endpoint was the development of a complication; the secondary endpoint was failure of reconstruction. RESULTS: Over the 2 year study period, 1170 expander/implant reconstructions were performed in 884 patients. The odds of developing complications was 2.2 times greater in smokers
McCarthy-Colleen-M, Mehrara-Babak-J, Riedel-Elyn et al
Abstract
BACKGROUND: Complications following postmastectomy reconstruction can cause significant morbidity. The compound effect of individual risk factors on the development of complications following expander /implant reconstruction has not, however, been well delineated. This study evaluated the impact of clinical risk factors to predict complications following postmastectomy expander/implant reconstruction. METHODS: From 2003 through 2004, 1170 expander /implant reconstructions were performed at a single center. A prospectively maintained database was reviewed. Variables including age, smoking status, body mass index, history of diabetes, hypertension, chemotherapy and/or radiation, as well as timing and laterality of reconstruction were evaluated. The primary endpoint was the development of a complication; the secondary endpoint was failure of reconstruction. RESULTS: Over the 2 year study period, 1170 expander/implant reconstructions were performed in 884 patients. The odds of developing complications was 2.2 times greater in smokers
Plastic and reconstructive surgery, Jun 2008, vol. 121, no. 6
p. 1875-85
Tepper-Oren-M, Choi-Mihye, Small-Kevin, Unger-Jacob et al
Abstract
BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three- dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three- dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively
Tepper-Oren-M, Choi-Mihye, Small-Kevin, Unger-Jacob et al
Abstract
BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three- dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three- dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively
Journal of the American College of Surgeons v.207 no.1 Jul 2008
Breast-conserving surgery using projection and reproduction techniques of surgical-position breast MRI in patients with ductal carcinoma in situ of the breast.
Journal of the American College of Surgeons, Jul 2008 (epub: 14 Apr 2008), vol. 207, no. 1
p. 62-8
Sakakibara-Masahiro, Nagashima-Takeshi, Sangai-Takafumi, Nakamura- Rikiya et al
Abstract
BACKGROUND: In this study, we report a breast-conserving surgery (BCS) approach that uses projection and reproduction techniques of breast MRI obtained in the surgical position to the breast surface in patients with ductal carcinoma in situ (DCIS) of the breast. STUDY DESIGN: Between February 2005 and January 2007, a total of 104 patients with operable breast cancer at our hospital had surgical- position breast MRI examinations. The 24 patients with relatively localized DCIS received BCS using the projection and reproduction techniques of the surgical-position breast MRI. During the same time period, 28 patients with relatively localized DCIS in whom prone- position breast MRI was performed, had conventional BCS using mammography-guided hookwires. In this study, we compared the surgical outcomes of our surgical approach with those of the conventional approach in a total of 52 patients with relatively localized DCIS. RESULTS: Average volume of the pathologic specimens in the new technique group (27.5 cm(3)) was substantially smaller than that in the conventional BCS group (57.6 cm(3), p = 0.0007). In addition, the positive margin rate was substantially lower in the new technique group (12.5%) than in the conventional BCS group (39.3%; p = 0.029). CONCLUSIONS: This study demonstrates that BCS can be done guided by the precise projection and reproduction techniques of the lesion obtained by surgical-position breast MRI. To the best of our knowledge, this is the first report of BCS technique for DCIS in this manner. Our surgical approach can be clinically useful in surgical planning and management in patients with DCIS.
Autologous breast reconstruction: the Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes.
Journal of the American College of Surgeons, Jul 2008 (epub: 05 May 2008), vol. 207, no. 1, p. 49-56
Greco-Joseph-A-3rd, Castaldo-Eric-T, Nanney-Lillian-B, Wu-Y-C, Donahue-Rafe et al
Abstract
BACKGROUND: Optimal surgical outcomes are dependent on an appreciation of comorbid conditions that may handicap results. The purpose of this retrospective analysis was to delineate risk factors for complications after autologous breast reconstruction. STUDY DESIGN: An institutional database was constructed of patients who underwent autologous breast reconstruction from 1998 to 2005. Variables captured included age, diabetes and smoking status, prereconstruction radiation therapy, concomitant breast resection, preoperative albumin, flap type, and body mass index (BMI; based on World Health Organization classifications: BMI>25, overweight; >30, obese). The primary outcome was noninfectious wound complications (NIWC), a novel classification based on the extent of tissue derangement and need for operative intervention. Secondary outcomes were wound infection, hematoma, hernia, and fat necrosis. Statistical analysis was performed using chi-square tests and multiple logistic regression. RESULTS: The analysis included 200 flaps (transverse rectus abdominis myocutaneous (TRAM)=171; latissimus dorsi=29) in 180 patients. There were 19 infections (9.5%), 3 total flap losses (1.5%) , 14 hematomas (7%), and 11 donor-site hernias (6%). The incidences of fat necrosis and any NIWC were 18% and 36%, respectively. Mean followup was 13.1 months (range 1.1 to 51.7 months). Multiple logistic regression demonstrated that obesity (BMI>30) is a statistically significant independent risk factor for any NIWC (hazards ratio=6.58; 95% CI, 2.85 to 15.18; p <>or=3; hazard ratio=6.23; 95% CI 2.15 to 18.05; p < 0.01). Increased BMI predicts NIWC, NIWC requiring operative intervention, and wound infection (p < 0.01). CONCLUSIONS: These data suggest that obesity is a strong predictor of simple and complex NIWC and of wound infection after autologous breast reconstruction. Obese patients should be counseled about their significantly increased risk of experiencing these unwanted outcomes.
Journal of the American College of Surgeons, Jul 2008 (epub: 14 Apr 2008), vol. 207, no. 1
p. 62-8
Sakakibara-Masahiro, Nagashima-Takeshi, Sangai-Takafumi, Nakamura- Rikiya et al
Abstract
BACKGROUND: In this study, we report a breast-conserving surgery (BCS) approach that uses projection and reproduction techniques of breast MRI obtained in the surgical position to the breast surface in patients with ductal carcinoma in situ (DCIS) of the breast. STUDY DESIGN: Between February 2005 and January 2007, a total of 104 patients with operable breast cancer at our hospital had surgical- position breast MRI examinations. The 24 patients with relatively localized DCIS received BCS using the projection and reproduction techniques of the surgical-position breast MRI. During the same time period, 28 patients with relatively localized DCIS in whom prone- position breast MRI was performed, had conventional BCS using mammography-guided hookwires. In this study, we compared the surgical outcomes of our surgical approach with those of the conventional approach in a total of 52 patients with relatively localized DCIS. RESULTS: Average volume of the pathologic specimens in the new technique group (27.5 cm(3)) was substantially smaller than that in the conventional BCS group (57.6 cm(3), p = 0.0007). In addition, the positive margin rate was substantially lower in the new technique group (12.5%) than in the conventional BCS group (39.3%; p = 0.029). CONCLUSIONS: This study demonstrates that BCS can be done guided by the precise projection and reproduction techniques of the lesion obtained by surgical-position breast MRI. To the best of our knowledge, this is the first report of BCS technique for DCIS in this manner. Our surgical approach can be clinically useful in surgical planning and management in patients with DCIS.
Autologous breast reconstruction: the Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes.
Journal of the American College of Surgeons, Jul 2008 (epub: 05 May 2008), vol. 207, no. 1, p. 49-56
Greco-Joseph-A-3rd, Castaldo-Eric-T, Nanney-Lillian-B, Wu-Y-C, Donahue-Rafe et al
Abstract
BACKGROUND: Optimal surgical outcomes are dependent on an appreciation of comorbid conditions that may handicap results. The purpose of this retrospective analysis was to delineate risk factors for complications after autologous breast reconstruction. STUDY DESIGN: An institutional database was constructed of patients who underwent autologous breast reconstruction from 1998 to 2005. Variables captured included age, diabetes and smoking status, prereconstruction radiation therapy, concomitant breast resection, preoperative albumin, flap type, and body mass index (BMI; based on World Health Organization classifications: BMI>25, overweight; >30, obese). The primary outcome was noninfectious wound complications (NIWC), a novel classification based on the extent of tissue derangement and need for operative intervention. Secondary outcomes were wound infection, hematoma, hernia, and fat necrosis. Statistical analysis was performed using chi-square tests and multiple logistic regression. RESULTS: The analysis included 200 flaps (transverse rectus abdominis myocutaneous (TRAM)=171; latissimus dorsi=29) in 180 patients. There were 19 infections (9.5%), 3 total flap losses (1.5%) , 14 hematomas (7%), and 11 donor-site hernias (6%). The incidences of fat necrosis and any NIWC were 18% and 36%, respectively. Mean followup was 13.1 months (range 1.1 to 51.7 months). Multiple logistic regression demonstrated that obesity (BMI>30) is a statistically significant independent risk factor for any NIWC (hazards ratio=6.58; 95% CI, 2.85 to 15.18; p <>or=3; hazard ratio=6.23; 95% CI 2.15 to 18.05; p < 0.01). Increased BMI predicts NIWC, NIWC requiring operative intervention, and wound infection (p < 0.01). CONCLUSIONS: These data suggest that obesity is a strong predictor of simple and complex NIWC and of wound infection after autologous breast reconstruction. Obese patients should be counseled about their significantly increased risk of experiencing these unwanted outcomes.
From Aunt Minnie.com - Breast MRI
Breast MRI is one of the most exciting clinical applications in medical imaging. But many questions remain, such as how it's being used in a clinical environment, in particular during breast screening.
A new study by a multicenter U.S. group answers many of these questions and is the subject of an article in our Women's Imaging Digital Community by staff writer Kate Madden Yee.
The study found that evaluating known malignant disease before treatment was the most common indication for breast MRI, followed by workup for suspicious lesions found on mammography or ultrasound. In a screening role, the most common application for breast MRI is to screen BRCA-positive women, who are known to be at higher risk of developing cancer.
Learn more by clicking here, [need to register] or visit our Women's Imaging Digital Community at women.auntminnie.com.
A new study by a multicenter U.S. group answers many of these questions and is the subject of an article in our Women's Imaging Digital Community by staff writer Kate Madden Yee.
The study found that evaluating known malignant disease before treatment was the most common indication for breast MRI, followed by workup for suspicious lesions found on mammography or ultrasound. In a screening role, the most common application for breast MRI is to screen BRCA-positive women, who are known to be at higher risk of developing cancer.
Learn more by clicking here, [need to register] or visit our Women's Imaging Digital Community at women.auntminnie.com.
Annals of Surgery August 2008 Volume 248 Issue 2
Feature
154-162 Are Many Community Hospitals Undertreating Breast Cancer?: Lessons From 24,834 Patients
Juan C. Gutierrez, MD; Judith D. Hurley, MD; Nadine Housri et al
Review
166-179 A Systematic Review of Skills Transfer After Surgical Simulation Training
Lana P. Sturm, BSc (Hons); John A. Windsor et al
280-285 The Effect of Dedicated Breast Surgeons on the Short-Term Outcomes in Breast Cancer
Noelia M. Zork, MD; Ian K. Komenaka, MD; Robert E. Pennington, Jr, et al
154-162 Are Many Community Hospitals Undertreating Breast Cancer?: Lessons From 24,834 Patients
Juan C. Gutierrez, MD; Judith D. Hurley, MD; Nadine Housri et al
Review
166-179 A Systematic Review of Skills Transfer After Surgical Simulation Training
Lana P. Sturm, BSc (Hons); John A. Windsor et al
280-285 The Effect of Dedicated Breast Surgeons on the Short-Term Outcomes in Breast Cancer
Noelia M. Zork, MD; Ian K. Komenaka, MD; Robert E. Pennington, Jr, et al
British journal of surgery Jul 2008 vol. 95 no. 7
Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma.
p. 827-33
Mhuircheartaigh-J-Ni, Curran-C, Hennessy-E, Kerin-M-J.
Abstract
BACKGROUND: Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome. METHODS: Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma. RESULTS: There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0.011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0.054). CONCLUSION: These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.
Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin.
p. 834-6
Hardy-R-G, Williams-L, Dixon-J-M.
Abstract
BACKGROUND: Low molecular weight heparin (LMWH) is used in preference to unfractionated heparin (UFH) for the prevention of postoperative thromboembolism in many UK surgical units. There are, however, conflicting reports on the relative risk of significant bleeding in surgical patients, and no data exist in the literature for patients undergoing breast surgery. METHODS: Data for patients in the Edinburgh Breast Unit with postoperative breast haematoma that needed surgical intervention were analysed for two 12-month intervals in which either UFH (2001) or LMWH (2005-2006) was used for thromboprophylaxis. Haematoma rates in the 6 months after UFH was reintroduced in 2006-2007 were also determined. RESULTS: The rate of haematoma requiring surgical intervention was 0.4 per cent (six of 1452 wounds) in patients who had UFH, compared with 1.8 per cent (32 of 1780 wounds) for LMWH. The rate fell to 0.5 per cent (four of 773 wounds) on reinstituting UFH. The relative risk of haematoma was significantly higher with LMWH than with UFH (4.00 (95 per cent confidence interval 1.97 to 8.11); P < 0.001). No significant postoperative thromboembolic complications were recorded. CONCLUSION: LMWH thromboprophylaxis was associated with a significant increase in haemorrhagic complications after breast surgery compared with UFH.
p. 827-33
Mhuircheartaigh-J-Ni, Curran-C, Hennessy-E, Kerin-M-J.
Abstract
BACKGROUND: Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome. METHODS: Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma. RESULTS: There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0.011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0.054). CONCLUSION: These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.
Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin.
p. 834-6
Hardy-R-G, Williams-L, Dixon-J-M.
Abstract
BACKGROUND: Low molecular weight heparin (LMWH) is used in preference to unfractionated heparin (UFH) for the prevention of postoperative thromboembolism in many UK surgical units. There are, however, conflicting reports on the relative risk of significant bleeding in surgical patients, and no data exist in the literature for patients undergoing breast surgery. METHODS: Data for patients in the Edinburgh Breast Unit with postoperative breast haematoma that needed surgical intervention were analysed for two 12-month intervals in which either UFH (2001) or LMWH (2005-2006) was used for thromboprophylaxis. Haematoma rates in the 6 months after UFH was reintroduced in 2006-2007 were also determined. RESULTS: The rate of haematoma requiring surgical intervention was 0.4 per cent (six of 1452 wounds) in patients who had UFH, compared with 1.8 per cent (32 of 1780 wounds) for LMWH. The rate fell to 0.5 per cent (four of 773 wounds) on reinstituting UFH. The relative risk of haematoma was significantly higher with LMWH than with UFH (4.00 (95 per cent confidence interval 1.97 to 8.11); P < 0.001). No significant postoperative thromboembolic complications were recorded. CONCLUSION: LMWH thromboprophylaxis was associated with a significant increase in haemorrhagic complications after breast surgery compared with UFH.
Postmastectomy radiation therapy.......
Postmastectomy radiation therapy for lymph node-negative, locally advanced breast cancer after modified radical mastectomy: analysis of the NCI Surveillance, Epidemiology, and End Results database.
Cancer, 1 Jul 2008, vol. 113, no. 1
p. 38-47
Yu-James-B, Wilson-Lynn-D, Dasgupta-Tina et al
Abstract
BACKGROUND: The role of postmastectomy radiotherapy (PMRT) for lymph node-negative locally advanced breast carcinoma (T3N0M0) after modified radical mastectomy (MRM) with regard to improvement in survival remains an area of controversy. METHODS: The 1973-2004 National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) database was examined for patients with T3N0M0 ductal, lobular, or mixed ductal and lobular carcinoma of the breast who underwent MRM, treated from 1988-2003. Patients who were men, who had positive lymph nodes, who survived < or =6 months, for whom breast cancer was not the first malignancy, who had nonbeam radiation, intraoperative or preoperative radiation were excluded. The average treatment effect of PMRT on mortality was estimated with a propensity score case-matched analysis. RESULTS: In all, 1777 patients were identified; 568 (32%) patients received PMRT. Median tumor size was 6.3 cm. The median number of lymph nodes examined was 14 (range, 1-49). Propensity score matched case-control analysis showed no improvement in overall survival with the delivery of PMRT in this group. Older patients, patients with ER- disease (compared with ER+), and patients with high-grade tumors (compared with well differentiated) had increased mortality. CONCLUSIONS: The use of PMRT for T3N0M0 breast carcinoma after MRM is not associated with an increase in overall survival. It was not possible to analyze local control in this study given the limitations of the SEER database. The impact of potential improvement in local control as it relates to overall survival should be the subject of further investigation.
Cancer, 1 Jul 2008, vol. 113, no. 1
p. 38-47
Yu-James-B, Wilson-Lynn-D, Dasgupta-Tina et al
Abstract
BACKGROUND: The role of postmastectomy radiotherapy (PMRT) for lymph node-negative locally advanced breast carcinoma (T3N0M0) after modified radical mastectomy (MRM) with regard to improvement in survival remains an area of controversy. METHODS: The 1973-2004 National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) database was examined for patients with T3N0M0 ductal, lobular, or mixed ductal and lobular carcinoma of the breast who underwent MRM, treated from 1988-2003. Patients who were men, who had positive lymph nodes, who survived < or =6 months, for whom breast cancer was not the first malignancy, who had nonbeam radiation, intraoperative or preoperative radiation were excluded. The average treatment effect of PMRT on mortality was estimated with a propensity score case-matched analysis. RESULTS: In all, 1777 patients were identified; 568 (32%) patients received PMRT. Median tumor size was 6.3 cm. The median number of lymph nodes examined was 14 (range, 1-49). Propensity score matched case-control analysis showed no improvement in overall survival with the delivery of PMRT in this group. Older patients, patients with ER- disease (compared with ER+), and patients with high-grade tumors (compared with well differentiated) had increased mortality. CONCLUSIONS: The use of PMRT for T3N0M0 breast carcinoma after MRM is not associated with an increase in overall survival. It was not possible to analyze local control in this study given the limitations of the SEER database. The impact of potential improvement in local control as it relates to overall survival should be the subject of further investigation.
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