Monday, 29 June 2015
Evolution of Bilateral Free Flap Breast Reconstruction over 10 Years: Optimizing Outcomes and Comparison to Unilateral Reconstruction
Plastic & Reconstructive Surgery: June 2015 - Volume
135 - Issue 6 - p 946e–953e
doi: 10.1097/PRS.0000000000001233
Chang, Edward I. et al
Background: There is an increasing
trend for contralateral prophylactic mastectomy, but studies focusing on
bilateral free flap breast reconstruction are lacking.
Methods: A retrospective review was
performed of all bilateral free flap breast reconstructions performed from 2000
to 2010.
Results: Overall, 488 patients
underwent bilateral breast reconstruction (bilateral immediate, n = 283;
bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which
more than doubled from the years 2000–2005 to 2006–2010 [147 versus 341 (232.0
percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a
similar increase over the decade [139 versus 282 (203.9 percent)]. There was an
increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared
to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17
percent)] between the first and second halves of the decade. Patients
undergoing a bilateral immediate/delayed reconstruction were significantly more
likely to undergo a revision (p = 0.05), particularly on the immediate
reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity
were significantly associated with postoperative complications. Obesity,
smoking, and radiation therapy significantly increased fat necrosis rates, 2.77
(p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In
comparison to unilateral reconstruction, bilateral reconstruction had
significantly higher flap loss rates (p = 0.004), comparable donor-site complications,
and equivalent rates of revisions.
Conclusions: There has been an increase in
bilateral free flap breast reconstruction. Bilateral immediate/delayed
reconstruction had higher revision rates of the prophylactic breast to achieve
symmetry. Obesity, smoking, and radiation therapy were associated with
increased complications, including fat necrosis, but successful reconstruction
can be achieved with acceptable risks.
Antibiotic Prophylaxis for Preventing Surgical-Site Infection in Plastic Surgery...
Plastic & Reconstructive Surgery: June 2015 - Volume
135 - Issue 6 - p 1723–1739 doi: 10.1097/PRS.0000000000001265
Ariyan, Stephan et al
Background: There is
a growing concern for microbial resistance as a result of overuse of
antibiotics. Although guidelines have focused on the use of antibiotics for
surgery in general, few have addressed plastic surgery specifically. The
objective of this expert consensus conference was to evaluate the evidence for
efficacy and safety of antibiotic prophylaxis in plastic surgical procedures.
Methods: The authors:
searched for existing high-quality systematic reviews for antibiotic
prophylaxis in the literature from the MEDLINE, Cochrane Library, and Embase
databases. All synonyms for antibiotics were combined with terms for relevant
plastic surgery procedures. The searches were not limited by language, and
included all study designs. In addition, supplemental hand searches were
performed of bibliographies of relevant articles, and extensive “related
articles.” Meta-analyses were performed and reviewed by experts selected by the
American Association of Plastic Surgeons to reach consensus recommendations.
Results: Database
searches identified 4300 articles, from which 2042 full-text articles were
identified for eligibility. De novo meta-analyses were performed for each
plastic surgical category. In total, 67 studies met the inclusion criteria,
including nine for breast surgery, 17 for head and neck surgery, 10 for
orthognathic surgery, seven for rhinoplasty/septoplasty, 19 for hand surgery,
five for skin surgery, and two for abdominoplasty.
Conclusions: Systemic
antibiotic prophylaxis is recommended for clean breast surgery and for
contaminated surgery of the hand or the head and neck. It is not recommended to
reduce infection in clean surgical cases of the hand, skin, head and neck, or
abdominoplasty.
Nipple-Sparing Mastectomy in Patients with Previous Breast Surgery: Comparative Analysis of 775 Immediate Breast Reconstructions
Plastic & Reconstructive Surgery: June 2015 - Volume
135 - Issue 6 - p 954e–962e
doi: 10.1097/PRS.0000000000001283
Frederick, Michael J. et al
Background: An
increasing number of women are candidates for nipple preservation with
mastectomy. It is unclear how previous breast surgery impacts nipple-sparing
mastectomy and immediate breast reconstruction.
Methods: A single-institution
retrospective review was performed between June of 2007 and June of 2013.
Results: Four hundred forty-four patients underwent 775 immediate breast
reconstructions after nipple-sparing mastectomy. Of these, 160 patients and 187
reconstructions had previous breast surgery, including 154 lumpectomies, 27
breast augmentations, and six reduction mammaplasties. Two hundred eighty-four
patients with 588 reconstructions without previous breast surgery served as the
control group. The previous breast surgery patients were older (49.6 years
versus 45.8 years; p < 0.001) but otherwise had similar demographics.
Previous breast surgery reconstructions were more often unilateral,
therapeutic, and associated with preoperative radiotherapy (p < 0.001 for
each). Extension of breast scars was common with previous breast surgery,
whereas the inframammary incision was most frequent if no scars were present (p
< 0.001). Multivariate regression analysis showed that previous breast
surgery was not a significant risk factor for ischemic complications or nipple
loss. Subgroup analysis showed extension of prior irradiated incisions was
predictive of skin flap necrosis (OR, 9.518; p = 0.05). A higher number of
lumpectomy patients had preoperative radiotherapy (41 versus 11; p < 0.001),
and patients with breast augmentation had more single-stage reconstructions
(85.2 percent versus 62.9 percent; p = 0.02).
Conclusion: Nipple-sparing
mastectomy and immediate reconstruction can be performed in patients with prior
breast surgery with no significant increase in nipple loss or ischemic
complications.
Bilateral Mastectomy versus Breast-Conserving Surgery for Early-Stage Breast Cancer:..
Albornoz, Claudia R et al
Plastic & Reconstructive Surgery: June 2015 - Volume
135 - Issue 6 - p 1518–1526
doi: 10.1097/PRS.0000000000001276
Background: Although
breast-conserving surgery is oncologically safe for women with early-stage
breast cancer, mastectomy rates are increasing. The objective of this study was
to examine the role of breast reconstruction in the surgical management of
unilateral early-stage breast cancer.
Methods: A retrospective cohort study of
women diagnosed with unilateral early-stage breast cancer (1998 to 2011)
identified in the National Cancer Data Base was conducted. Rates of
breast-conserving surgery, unilateral and bilateral mastectomy with
contralateral prophylactic procedures (per 1000 early-stage breast cancer
cases) were measured in relation to breast reconstruction. The association
between breast reconstruction and surgical treatment was evaluated using a
multinomial logistic regression, controlling for patient and disease
characteristics.
Results: A total of 1,856,702 patients were included.
Mastectomy rates decreased from 459 to 360 per 1000 from 1998 to 2005 (p <
0.01), increasing to 403 per 1000 in 2011 (p < 0.01). The mastectomy rates
rise after 2005 reflects a 14 percent annual increase in contralateral
prophylactic mastectomies (p < 0.01), as unilateral mastectomy rates did not
change significantly. Each percentage point of increase in reconstruction rates
was associated with a 7 percent increase in the probability of contralateral
prophylactic mastectomies, with the greatest variation explained by young
age(32 percent), breast reconstruction (29 percent), and stage 0 (5 percent).
Conclusions: Since 2005, an increasing proportion of early-stage breast cancer
patients have chosen mastectomy instead of breast-conserving surgery. This
trend reflects a shift toward bilateral mastectomy with contralateral
prophylactic procedures that may be facilitated by breast reconstruction
availability.
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