Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Ann Surg Oncol. 2016 Mar 4. [Epub ahead of print]

Dolen UC et al


BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking.
METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal.
RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035).

DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review

Plastic & Reconstructive Surgery: March 2016 - Volume 137 - Issue 3 - p 826–841 doi: 10.1097/01.prs.0000480095.23356.ae


Wan, D, Rohrich, R



Background: Capsular contracture is a complication of breast augmentation that frequently requires revision surgery. “Capsulectomy, site change, and implant exchange” has been referred to as the gold standard treatment of clinically significant contractures. However, the actual clinical evidence behind this algorithm remains elusive at best. A systematic review of the literature was performed to clarify the true evidence behind the surgical management of capsular contracture. Methods: A search of the MEDLINE database was performed for clinical studies involving the surgical treatment of capsular contracture following breast augmentation. Resulting articles were reviewed using a priori criteria. Results: The systematic review was performed in April of 2015. The primary search for “breast augmentation” yielded 9490 articles. When filtered for “treatment of capsular contracture,” 461 articles resulted. Review of these articles and pertinent references using a priori criteria yielded 24 final articles. No controlled trials met final inclusion criteria. Conclusions: There is limited clinical evidence behind the surgical management of capsular contracture. Site change and implant exchange are associated with reduced contracture recurrence rates and likely play a beneficial role in treating capsular contracture. The data on capsulectomy are less conclusive. Acellular dermal matrix may be a useful adjunct but still requires long-term data.

A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study

A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study

Plastic & Reconstructive Surgery: February 2016 - Volume 137 - Issue 2 - p 395–401 doi: 10.1097/01.prs.0000475744.10344.1e


Rinker, B et al

BACKGROUND: Skin-sparing mastectomy with immediate reconstruction can yield excellent aesthetic results, but high rates of mastectomy flap necrosis have been reported. A prospective cohort study was undertaken to compare three methods of assessing mastectomy flap viability following skin-sparing mastectomy and immediate reconstruction to determine which is most effective in reducing mastectomy flap necrosis.
METHODS: The study group included 60 consecutive patients (99 breasts) undergoing skin-sparing mastectomy and immediate reconstruction with either tissue expanders (n = 39) or transverse rectus abdominis musculocutaneous flaps (n = 21). Mastectomy flap viability was assessed either visually (n = 20), with fluorescein dye and Wood's lamp imaging (n = 20), or by indocyanine green angiography (n = 20). Variation across groups was analyzed using analysis of variance for continuous variables and chi-square test for dichotomous variables.
RESULTS: The mean follow-up was 10 months. There were no significant differences in mean age, body mass index, medical history, smoking history, pathologic diagnosis, chemotherapy, or reconstruction type. Mastectomy flap necrosis was observed in eight of 30 breasts in the direct visualization group (27 percent), compared with 14 percent in the indocyanine green angiography group and 3 percent in the fluorescein group (p = 0.03). The reoperation rate in the direct visualization group was 20 percent, compared with 15 percent in the indocyanine green angiography group and 0 percent in the fluorescein group.

CONCLUSIONS: Fluorescein dye was associated with the lowest rate of complications after skin-sparing mastectomy, but indocyanine green angiography was also shown to reduce mastectomy flap necrosis compared with direct visualization. Routine imaging of mastectomy flap perfusion seems to be beneficial in skin-sparing mastectomy, but intravenous fluorescein may be as effective as more expensive modalities.

Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction: 71 Breast Reconstructions in 53 Consecutive Patients

Using the Retrograde Internal Mammary System for Stacked Perforator Flap Breast Reconstruction: 71 Breast Reconstructions in 53 Consecutive Patients

Plastic & Reconstructive Surgery: February 2016 - Volume 137 - Issue 2 - p 265e–277e doi:10.1097/01.prs.0000475743.08559.b6

Stalder, M et al


Background: Abdominal tissue is the preferred donor source for autologous breast reconstruction, but in select patients with inadequate tissue, additional volume must be recruited to achieve optimal outcomes. Stacked flaps are an effective approach in these cases, but can be limited by the need for adequate recipient vessels. This article reports outcomes for the use of the retrograde internal mammary system for stacked flap breast reconstruction in a large number of consecutive patients. Methods: Fifty-three patients underwent stacked autologous tissue breast reconstruction with a total of 142 free flaps. Thirty patients underwent unilateral stacked deep inferior epigastric perforator (DIEP) flap reconstruction, five had unilateral stacked profunda artery perforator flap reconstruction, one had bilateral stacked DIEP/superior gluteal artery perforator flap reconstruction, and 17 underwent bilateral stacked DIEP/profunda artery perforator flap reconstruction. In all cases, the antegrade and retrograde internal mammary vessels were used for anastomoses. In situ manometry studies were also conducted comparing the retrograde internal mammary arteries in 10 patients to the corresponding systemic pressures. Results: There were three total flap losses (97.9 percent flap survival rate), two partial flap losses, four reexplorations for venous congestion, and three patients with operable fat necrosis. The mean weight of the stacked flaps for each reconstructed breast was 622.8 g. The retrograde internal mammary mean arterial pressures were on average 76.6 percent of the systemic mean arterial pressures. Conclusions: The results demonstrate that the retrograde internal mammary system is capable of independently supporting free tissue transfer. These vessels provide for convenient dissection and improved efficiency of these cases, with successful postsurgical outcomes.

Time for a randomised clinical trial evaluating breast conserving surgery compared to mastectomy in ipsilateral mutlifocal breast cancer (MFBC)?

Time for a randomised clinical trial evaluating breast conserving surgery compared to mastectomy in ipsilateral mutlifocal breast cancer (MFBC)?

The Breast [Article in Press]

Winters Z et al

Nijenhuis et al. (2015) are to be commended for reviewing the role of breast-conserving surgery (BCS) in the treatment of Multifocal Breast Cancers (MFBC) [1]. Currently, evidence-based guidelines on recommended surgical treatments in MFBC are based on limited evidence. A systematic review [2] critically evaluating the published literature has led us to conclude the following: 1) Studies of MFBC would benefit from standardized imaging, ideally with MRI providing detailed and accurate anatomic extent; 2) Modern trials would ideally evaluate neoadjuvant therapy, where therapeutic response can be evaluated; 3) Tumour subtype (immunohistochemical markers) of each cancer should be used in a minimized randomization design; 4) There is poor clinical evidence for the feasibility of dual tumour bed radiotherapy (RT) boosting and its impact on outcomes; 5) Meta-analyses on RT for unifocal cancers underline the significance of 10-year first recurrence and not breast cancer death; 6) Effect-sizes for 5-year local recurrence requires intergroup comparisons of surgery types (BCS versus mastectomy) far in excess of reported studies, where multicentric cancers are included and MFBC are clinically diagnosed; 7) Lack of convincing outcomes data on 5-year local recurrence after BCS is motivating a large international collaborative supported by respective international and national associations of breast surgery.

Patient-reported outcomes and their predictors at 2- and 3-year follow-up after immediate latissimus dorsi breast reconstruction and adjuvant treatment.

Br J Surg. 2016 Feb 29. doi: 10.1002/bjs.10102. [Epub ahead of print]

Winters Z E, et al


BACKGROUND: The aim of this study was to estimate the impact 2 and 3 years after surgery of implant-assisted latissimus dorsi (LDI) and autologous latissimus dorsi (ALD) flap breast reconstructions on patient-reported outcomes (PROs), and, secondarily, to determine whether baseline characteristics can predict PROs.
METHODS: This was a multicentre prospective cohort study. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30) and breast cancer module (QLQ-BR23), Functional Assessment of Cancer Therapy - Breast (FACT-B), and Hospital Anxiety and Depression Scale (HADS) PROs were completed before surgery and at 2 and 3 years after breast reconstruction. The effects of LDI and ALD, adjusted for baseline clinicodemographic characteristics, were estimated with multiple linear regressions. Effect sizes above 0·5 were considered clinically important.
RESULTS: Some 206 patients (LDI 93, ALD 113) were recruited in 2007-2013; 66·5 per cent were node-negative and 34·6 per cent received radiotherapy. Women with adverse clinicopathological factors were more likely to have received radiotherapy and to undergo ALD. Patients in both surgical groups showed clinically important effects at 2 and 3 years, including improvements in emotional scales, but worse physical functioning, social well-being, body image and anxiety. Radiotherapy adversely affected social functioning at 2 years (P = 0·002). Women undergoing ALD reconstruction had significantly improved sexual functioning at 3 years (P = 0·003) relative to those who had LDI procedures, even after adjusting for case mix (P = 0·007). At 3 years, younger women experienced worse physical well-being than older women (P = 0·006), and chemotherapy was associated with worse arm symptoms (P = 0·005).

CONCLUSION: Clinically important changes occurred in physical functioning, breast symptoms, body image and psychological distress. These results will guide selections of key PRO domains and sample-size calculation of future studies.

Implant-based breast reconstruction:Strategies to achieve optimal outcomes and minimize complications.

J Surg Oncol. 2016 Feb 26. doi: 10.1002/jso.24210. [Epub ahead of print]

Nahabedian MY

Abstract: Breast reconstruction using prosthetic devices is the most commonly performed procedure in women following mastectomy. The goal is to provide an outcome that is predictable and reproducible while minimizing complications and optimizing aesthetics. There are various strategies by which this can be achieved. It begins with proper patient selection because most adverse events occur in high-risk patients. This in turn is related to the timing of the reconstruction that can be performed immediately following the mastectomy or on a delayed basis. Many surgeons have been combining the use of acellular dermal matrices with prosthetic devices that require strict attention to detail to ensure success. There are various options for achieving device coverage that include total muscle, partial muscle, and subcutaneous coverage. The radiated patient poses additional challenges and limitations that must be understood to achieve a desired outcome. Finally, autologous fat grafting has become a valuable tool to improve outcomes in both radiated and non-radiated women. These factors will be reviewed with the intent of improving outcomes and minimizing complications in the setting of prosthetic breast reconstruction.