Monday, 29 June 2015

Nipple-Sparing Mastectomy and Ptosis: Perforator Flap Breast Reconstruction .................

Plastic & Reconstructive Surgery: July 2015 - Volume 136 - Issue 1 - p 1e–9e
doi: 10.1097/PRS.0000000000001325

DellaCroce, Frank J. et al.

Background: Patients with moderate to severe ptosis are often considered poor candidates for nipple-sparing mastectomy. This results from the perceived risk of nipple necrosis and/or the inability of the reconstructive surgeon to reliably and effectively reposition the nipple-areola complex on the breast mound after mastectomy.
Methods: A retrospective review identified patients with grade II/III ptosis who underwent nipple-sparing mastectomy with immediate perforator flap reconstruction and subsequently underwent a mastopexy procedure. The mastopexies included complete, full-thickness periareolar incisions with peripheral undermining around the nipple-areola complex to allow for full transposition of the nipple-areola complex relative to the surrounding skin envelope.
Results: Seventy patients with 116 nipple-sparing mastectomies met inclusion criteria. The most common complications were minor incisional dehiscence (7.7 percent) and variable degrees of necrosis in the preserved breast skin (3.4 percent) after the initial mastectomy. There were no cases of nipple-areola complex necrosis following the secondary mastopexy.
Conclusions: The authors demonstrate that full mastopexy, including a complete full-thickness periareolar incision and nipple-areola complex repositioning on the breast mound, can be safely performed after nipple-sparing mastectomy and perforator flap breast reconstruction. The underlying flap provides adequate vascular ingrowth to support the perfusion of the nipple-areola complex despite complete incisional interruption of the surrounding cutaneous blood supply. These findings may allow for inclusion of women with moderate to severe ptosis in the candidate pool for nipple-sparing mastectomy if oncologic criteria are otherwise met. These findings also represent a significant potential advantage of autogenous reconstruction over implant reconstruction in women with breast ptosis who desire nipple-sparing mastectomy.

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.