Thursday, 4 February 2016

Lipofilling of the Breast Does Not Increase the Risk of Recurrence of Breast Cancer: A Matched Controlled Study

Lipofilling of the Breast Does Not Increase the Risk of Recurrence of Breast Cancer: A Matched Controlled Study
Plastic & Reconstructive Surgery:
February 2016 - Volume 137 - Issue 2 - p 385–393
Kronowitz, S et al.

Background: Although many plastic surgeons perform autologous fat grafting (lipofilling) for breast reconstruction after oncologic surgery, it has not been established whether postoncologic lipofilling increases the risk of breast cancer recurrence. The authors assessed the risk of locoregional and systemic recurrence in patients who underwent lipofilling for breast reconstruction. Methods: The authors identified all patients who underwent segmental or total mastectomy for breast cancer (719 breasts) (i.e., cases) or breast cancer risk reduction or benign disease (305 cancer-free breasts) followed by breast reconstruction with lipofilling as an adjunct or primary procedure between June of 1981 and February of 2014. They also then identified matched patients with breast cancer treated with segmental or total mastectomy followed by reconstruction without lipofilling (670 breasts) (i.e., controls). The probability of locoregional recurrence was estimated by the Kaplan-Meier method. Results: Mean follow-up times after mastectomy were 60 months for cases, 44 months for controls, and 73 months for cancer-free breasts. Locoregional recurrence was observed in 1.3 percent of cases (nine of 719 breasts) and 2.4 percent of controls (16 of 670 breasts). Breast cancer did not develop in any cancer-free breast. The cumulative 5-year locoregional recurrence rates were 1.6 percent and 4.1 percent for cases and controls, respectively. Systemic recurrence occurred in 2.4 percent of cases and 3.6 percent of controls (p = 0.514). There was no primary breast cancer in healthy breasts reconstructed with lipofilling. Conclusions: The study results showed no increase in locoregional recurrence, systemic recurrence, or second breast cancer. These findings support the oncologic safety of lipofilling in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Volumetric Evaluation of the Mammary Gland and Pectoralis Major Muscle following Subglandular and Submuscular Breast Augmentation

Volumetric Evaluation of the Mammary Gland and Pectoralis Major Muscle following Subglandular and Submuscular Breast Augmentation
Plastic & Reconstructive Surgery:
January 2016 - Volume 137 - Issue 1 - p 62–69
Weck Roxo, A et al

Background: Besides being a procedure with high level of patient satisfaction, one of the main causes for reoperation after breast augmentation is related to contour deformities and changes in breast volume. Few objective data are available on postoperative volumetric analysis following breast augmentation. The aim of this study was to evaluate volume changes in the breast parenchyma and pectoralis major muscle after breast augmentation with the placement of silicone implants in the subglandular and submuscular planes. Methods: Fifty-eight women were randomly allocated either to the subglandular group (n = 24) or submuscular group (n = 24) and underwent breast augmentation in the subglandular or submuscular plane, respectively, or to a control group (n = 10) and received no intervention. Volumetric magnetic resonance imaging was performed at inclusion in all participants and either after 6 and 12 months in the control group or at 6 and 12 months after surgery in the intervention groups. Results: Twelve months after breast augmentation, only the subglandular group had a significant reduction in glandular volume (mean, 22.8 percent), while patients in the submuscular group were the only ones showing significant reduction in muscle volume (mean, 49.80 percent). Conclusions: Atrophy of the breast parenchyma occurred after subglandular breast augmentation, but not following submuscular breast augmentation. In contrast, submuscular breast augmentation caused atrophy of the pectoralis major muscle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The quality of preoperative diagnostics and surgery and their impact on delays in breast cancer treatment – A population based study

 The Breast April 2016 Volume 26, Pages 80–86
Ojala K, Meretoja TJ, Mattson J, Salminen-Peltola P, Leutola S, Berggren M, . Leidenius M HK.
This study aims to clarify quality of breast cancer surgery in population-based setting. We aim to elucidate factors influencing waiting periods, and to evaluate the effect of hospital volume on surgical treatment policies. Special interest was given to diagnostic and surgical processes and their impact on waiting times.

A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction

A Systematic Review of Comparison of Autologous,Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction
Plastic & Reconstructive Surgery:
January 2016 - Volume 137 - Issue 1 - p 14e–23e
Winocour, S et al.

Background: Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. Methods: MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. Results: Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars. Conclusions: The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

DIEAP flap for safe definitive autologous breast reconstruction

DIEAP flap for safe definitive autologous breastreconstruction
The Breast April 2016 Volume 26, Pages 59–66

Katrin Seidenstuecker, Carl van Waes, Beatrix I. Munder, Karel E.Y. Claes, Christian Witzel, Nathalie Roche, Filip Stillaert, Ajay L. Mahajan Christoph Andree, Phillip N. Blondeel

Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. 

Natrelle Silicone Breast Implant Follow-Up Study: Demographics, Lifestyle, and Surgical Characteristics of More Than 50,000 Augmentation Subjects

Natrelle Silicone Breast Implant Follow-Up Study:Demographics, Lifestyle, and Surgical Characteristics of More Than 50,000 Augmentation Subjects
Plastic & Reconstructive Surgery:
January 2016 - Volume 137 - Issue 1 - p 70–81
Singh, N, Picha, G, Murphy, D

Background: A large, multicenter, 10-year observational study is being conducted to compare the long-term safety and effectiveness of Natrelle silicone breast implants with saline implants or national norms. Study baseline data and surgical characteristics are reported here. Methods: Women seeking primary augmentation, revision-augmentation, primary reconstruction, or revision-reconstruction participated. Eligible subjects had completed surgery and received one implant or matching implants. Baseline demographics, health, lifestyle, and surgical characteristics were recorded. Data are presented here for subjects (≥22 years old) who underwent primary augmentation or revision-augmentation. Results: Of 50,979 subjects who underwent augmentation procedures, 35,756 received silicone implants and 15,223 received saline implants. Of these, 86.3 percent underwent primary augmentation, and 13.7 percent underwent revision-augmentation; nearly all subjects (99.3 percent) received bilateral implants. In the primary augmentation group, 67.6 percent of subjects received silicone implants versus 86.1 percent in the revision-augmentation group. Median age was lower in the primary augmentation group compared with the revision-augmentation group (33 versus 42 years old, respectively). Most subjects were white nonsmokers and had attended college. Hispanic subjects and subjects with a body mass index of 25 kg/m2 or greater were more likely to receive saline versus silicone implants. Across groups, the most common characteristics by procedure or implant type included inframammary incision site (54.6 percent), partial (58.2 percent) or complete (31.9 percent) submuscular placement, smooth surface implants (93.1 percent), and implant size of 300 to 399 cc. Incision size was larger for silicone versus saline implants. Conclusion: These data add to the body of knowledge on women undergoing augmentation procedures by providing an unprecedented look at a large number of subjects.

The Use of Autologous Fat Grafting for Treatment of Scar Tissue and Scar-Related Conditions: A Systematic Review

The Use of Autologous Fat Grafting for Treatmentof Scar Tissue and Scar-Related Conditions: A Systematic Review
Plastic & Reconstructive Surgery: January 2016 - Volume 137 - Issue 1 - p 31e–43e
Negenborn, V et al.

Background: Scar tissue can cause cosmetic impairments, functional limitations, pain, and itch. It may also cause emotional, social, and behavioral problems, especially when it is located in exposed areas. To date, no gold standard exists for the treatment of scar tissue. Autologous fat grafting has been introduced as a promising treatment option for scar tissue-related symptoms. However, the scientific evidence for its effectiveness remains unclear. This systematic review aims to evaluate the available evidence regarding the effectiveness of autologous fat grafting for the treatment of scar tissue and scar-related conditions. Methods: A systematic literature review was performed using MEDLINE, Cochrane Library, EMBASE, and Web of Science. No language restrictions were imposed. Results: Twenty-six clinical articles were included, reporting on 905 patients in total. Meta-analysis was not performed because of the heterogeneous methodology demonstrated among the articles. Main outcome measures were scar appearance and skin characteristics, restoration of volume and/or (three-dimensional) contour, itch, and pain. All publications report a beneficial effect of autologous fat grafting on scar tissue. There is statistical significant improvement of the scar appearance, skin characteristics, and pain. Itch and restoration of volume and three-dimensional contour also improved. Conclusions: Autologous fat grafting is used to improve a variety of symptoms related to scar tissue. This systematic review suggests that autologous fat grafting provides beneficial effects with limited side effects. However, the level of evidence and methodological quality are quite low. Future randomized controlled trials with a methodologically strong design are necessary to confirm the effects of autologous fat grafting on scar tissue and scar-related conditions.

Carbon Dioxide versus Saline Tissue Expanders: Does It Matter?

Carbon Dioxide versus Saline Tissue Expanders:Does It Matter?

Plastic & Reconstructive Surgery:

January 2016 - Volume 137 - Issue 1 - p 31–35
Ascherman, J et al

Background: Implant-based breast reconstruction is the most common reconstructive technique in the United States. Despite its popularity, saline-based tissue expansion still has its limitations, including lengthy expansion times, large uncomfortable bolus dosing, and frequent percutaneous injections/expansion visits. Ideally, a novel technology would eliminate frequent, percutaneous saline injections and allow patients to perform expansion at home, reducing the disruptive experience of current tissue expansion. Methods: Within the past 6 years, the AeroForm tissue expander system has used remotely activated carbon dioxide release as the fill medium instead of saline, eliminating many limitations of traditional tissue expanders. In this article, the authors first review the relevant literature concerning carbon dioxide–based tissue expansion in animal and human models. The authors then analyze the similarities and differences between two groundbreaking human trials (i.e., Patient Activated Controlled Expansion and AirXpanders Patient Activated Controlled Tissue Expander) with carbon dioxide–based expanders and discuss the risks and benefits associated with this new technology. Results: At their site, the authors have enrolled 34 patients using 36 experimental devices in total, and have found significantly shorter expansion and overall reconstruction times in the patient-controlled tissue expander group. Conclusions: The authors believe that carbon dioxide–based devices may play a significant role in the future of implant-based breast reconstruction, and may be widely applicable to other areas of plastic surgery that also involve tissue expansion.

Over Troubled Water: An Outbreak of Infection Due to a New Species of Mycobacterium following Implant-Based Breast Surgery

Plastic & Reconstructive Surgery: January 2016 - Volume 137 - Issue 1 - p 97–105

Scheflan, M, Wixtrom, R

Summary: Mycobacterial infection is a rare complication associated with breast surgery using implants. Over the course of 5 months, one center experienced 12 such cases, 10 of which were linked to a single surgeon. Most presented 3 to 6 weeks postoperatively with clear serous drainage from the incision, minimal local redness, no fever or other systemic signs of infection, and negative standard bacterial cultures. Patients were given empiric broad-spectrum oral antibiotic therapy. In eight cases, implants were removed and exchanged for new devices after irrigation of the pocket with antibiotics; these patients nonetheless experienced recurrent infection, which led to explantation (without immediate exchange for new implants). The last two patients proceeded straight to explantation. Because mycobacteria grow in water, the water supply and air-conditioning system were initially suspected as the source, and both were disinfected. However, this did not stop the outbreak. Eventually, the source was traced to a new species of mycobacteria isolated from a garden hot tub. These bacteria had then been unwittingly transferred to patients during surgery. A Triclosan-containing shampoo effectively ended the outbreak. This series is unique in several respects: the novelty of the pathogen, the heavy colonization of the surgeon, and the mechanism of transmission (the first occurrence of human-to-human mycobacterial transfer published in the plastic surgery literature). Surgeons who perform breast surgery with implants should be aware of the possibility of mycobacterial infection. Proactive culturing of the organism, use of antibiotics, and reoperation are essential to good outcomes.