Finding the balance between over- and under-treatment of ductal carcinoma in situ (DCIS)
Groen EJ et al
The Breast: Article in Press
With the widespread adoption of population-based breast cancer screening, ductal carcinoma in situ (DCIS) has come to represent 20–25% of all breast neoplastic lesions diagnosed. Current treatment aims at preventing invasive breast cancer, but the majority of DCIS lesions will never progress to invasive disease. Still, DCIS is treated by surgical excision, followed by radiotherapy as part of breast conserving treatment, and/or endocrine therapy. This implies over-treatment of the majority of DCIS, as less than 1% of DCIS patients will go on to develop invasive breast cancer annually.
Tuesday, 18 October 2016
A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients
A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients
Huo J et al
The Breast December 2016Volume 30, Pages 118–124
The objectives of this study were to compare, by patient obesity status, the contemporary utilization patterns of different reconstruction surgery types, understand postoperative complication profiles in the community setting, and analyze the financial impact on health care payers and patients.
Huo J et al
The Breast December 2016Volume 30, Pages 118–124
The objectives of this study were to compare, by patient obesity status, the contemporary utilization patterns of different reconstruction surgery types, understand postoperative complication profiles in the community setting, and analyze the financial impact on health care payers and patients.
Postmastectomy Radiation Therapy and Two-Stage Implant-Based Breast Reconstruction: Is There a Better Time to Irradiate?
Postmastectomy Radiation Therapy and Two-Stage Implant-Based Breast Reconstruction: Is There a Better Time to Irradiate?
Santosa, K et al,
Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 761–769
Background: The ideal timing of postmastectomy radiation therapy (PMRT) in the setting of two-stage implant-based breast reconstruction remains unclear. In this cohort study, the authors sought to determine whether complication rates differed between patients who received PMRT following tissue expander placement (TE-XRT) and those who received PMRT after exchange for permanent implants (Implant-XRT) utilizing using prospective, multicenter data.
Methods: Eligible patients in the Mastectomy Reconstruction Outcomes Consortium study from 11 institutions across North America were included in the analysis. All patients had at least 6-month follow-up after their last intervention (i.e., implant exchange for TE-XRT patients, and radiation for Implant-XRT patients). Complications including seroma, hematoma, infection, wound dehiscence, capsular contracture, and implant loss were recorded.
Results: The authors identified a total of 150 patients who underwent immediate, two-stage implant-based breast reconstruction and received PMRT. Of these, there were TE-XRT 104 patients (69.3 percent) and 46 (30.7 percent) Implant-XRT patients. There were no differences in the incidence of any complications or complications leading to reconstructive failure between the two cohorts. After adjusting for patient characteristics and site effect, the timing of PMRT (i.e., TE-XRT versus Implant-XRT) was not a significant predictor in the development of any complication, a major complication, or reconstructive failure.
Conclusion: In the setting of PMRT and two-stage implant-based reconstruction, patients who received PMRT after expander placement (TE-XRT) did not have a higher incidence or increased odds of developing complications than those who received PMRT after exchange for a permanent implant (Implant-XRT).
Santosa, K et al,
Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 761–769
Background: The ideal timing of postmastectomy radiation therapy (PMRT) in the setting of two-stage implant-based breast reconstruction remains unclear. In this cohort study, the authors sought to determine whether complication rates differed between patients who received PMRT following tissue expander placement (TE-XRT) and those who received PMRT after exchange for permanent implants (Implant-XRT) utilizing using prospective, multicenter data.
Methods: Eligible patients in the Mastectomy Reconstruction Outcomes Consortium study from 11 institutions across North America were included in the analysis. All patients had at least 6-month follow-up after their last intervention (i.e., implant exchange for TE-XRT patients, and radiation for Implant-XRT patients). Complications including seroma, hematoma, infection, wound dehiscence, capsular contracture, and implant loss were recorded.
Results: The authors identified a total of 150 patients who underwent immediate, two-stage implant-based breast reconstruction and received PMRT. Of these, there were TE-XRT 104 patients (69.3 percent) and 46 (30.7 percent) Implant-XRT patients. There were no differences in the incidence of any complications or complications leading to reconstructive failure between the two cohorts. After adjusting for patient characteristics and site effect, the timing of PMRT (i.e., TE-XRT versus Implant-XRT) was not a significant predictor in the development of any complication, a major complication, or reconstructive failure.
Conclusion: In the setting of PMRT and two-stage implant-based reconstruction, patients who received PMRT after expander placement (TE-XRT) did not have a higher incidence or increased odds of developing complications than those who received PMRT after exchange for a permanent implant (Implant-XRT).
Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?
Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?
Phillips, BT, Halvorson, EG.
Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 751–757
Background: Although data from other surgical disciplines do not support the use of prolonged postoperative prophylactic antibiotics, implant-based breast reconstruction is one area of plastic surgery where this may be warranted. The purpose of this study was to review the literature on antibiotic prophylaxis in prosthetic breast reconstruction, summarize findings, and provide recommendations.
Methods: A literature review was performed to identify studies that compared different perioperative prophylactic antibiotic regimens with respect to infectious outcomes in prosthetic breast reconstruction.
Results: Five studies and five systematic reviews were identified. One prospective randomized trial showed that a single preoperative dose was better than placebo, and another showed no difference between 24 hours versus until drain removal. Three studies were retrospective, one showing no difference between a single preoperative dose and prolonged antibiotic use, and two showing significant reduction in infectious complications with prolonged antibiotic use. One systematic review suggested an increased rate of infection with prolonged antibiotic use, and the other showed no difference between less than 24 hours and greater than 24 hours, but showed a reduction in infections compared to no treatment.
Conclusions: The literature contains conflicting data regarding the optimal duration for perioperative antibiotic prophylaxis following prosthetic breast reconstruction. The authors’ opinion is that 24 hours of antibiotic prophylaxis is warranted. Further studies are needed. Patient-centered antibiotic prophylaxis based on a risk-assessment model may be a more effective alternative to the current indiscriminate model of surgical-site infection control.
Phillips, BT, Halvorson, EG.
Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 751–757
Background: Although data from other surgical disciplines do not support the use of prolonged postoperative prophylactic antibiotics, implant-based breast reconstruction is one area of plastic surgery where this may be warranted. The purpose of this study was to review the literature on antibiotic prophylaxis in prosthetic breast reconstruction, summarize findings, and provide recommendations.
Methods: A literature review was performed to identify studies that compared different perioperative prophylactic antibiotic regimens with respect to infectious outcomes in prosthetic breast reconstruction.
Results: Five studies and five systematic reviews were identified. One prospective randomized trial showed that a single preoperative dose was better than placebo, and another showed no difference between 24 hours versus until drain removal. Three studies were retrospective, one showing no difference between a single preoperative dose and prolonged antibiotic use, and two showing significant reduction in infectious complications with prolonged antibiotic use. One systematic review suggested an increased rate of infection with prolonged antibiotic use, and the other showed no difference between less than 24 hours and greater than 24 hours, but showed a reduction in infections compared to no treatment.
Conclusions: The literature contains conflicting data regarding the optimal duration for perioperative antibiotic prophylaxis following prosthetic breast reconstruction. The authors’ opinion is that 24 hours of antibiotic prophylaxis is warranted. Further studies are needed. Patient-centered antibiotic prophylaxis based on a risk-assessment model may be a more effective alternative to the current indiscriminate model of surgical-site infection control.
A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study
A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study
Zhong T et al
Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 772–780
Background: This is the first study to use generic distress, cancer-specific, and procedure-specific measures to prospectively evaluate psychological responses, body image, sexuality, and health-related quality of life in immediate compared with delayed breast reconstruction. Methods: Consecutive patients undergoing autologous immediate and delayed breast reconstruction (June of 2009 to December of 2010) completed the Hospital Anxiety and Depression Scale, Body Image Scale, Sexuality Scale, and BREAST-Q preoperatively and postoperatively (6, 12, and 18 months). Linear mixed-effects analyses between each outcome and time point were performed. Results: One hundred six women underwent mastectomy with immediate (n = 30) and delayed breast reconstruction (n = 76). Before reconstruction, 26 percent of patients had abnormal anxiety scores and 9 percent had abnormal depression scores, with no significant differences between groups. Patients awaiting delayed breast reconstruction had significantly impaired prereconstruction body image (p = 0.01) and sexuality (p = 0.01) and worse satisfaction with breast (p < 0.01), psychological (p < 0.01), and sexual well-being (p < 0.01). At 18 months after immediate and delayed breast reconstruction, there was significant improvement in anxiety, depression, body image, sexuality, and health-related quality of life. Conclusions: This single-center study shows that mastectomy with immediate breast reconstruction may protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with those waiting for delayed breast reconstruction. In patients who are oncologically eligible and strongly interested in breast reconstruction, efforts should be made to provide immediate breast reconstruction to decrease the interval of psychosocial distress, poor body image, and impaired sexuality.
Zhong T et al
Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 772–780
Background: This is the first study to use generic distress, cancer-specific, and procedure-specific measures to prospectively evaluate psychological responses, body image, sexuality, and health-related quality of life in immediate compared with delayed breast reconstruction. Methods: Consecutive patients undergoing autologous immediate and delayed breast reconstruction (June of 2009 to December of 2010) completed the Hospital Anxiety and Depression Scale, Body Image Scale, Sexuality Scale, and BREAST-Q preoperatively and postoperatively (6, 12, and 18 months). Linear mixed-effects analyses between each outcome and time point were performed. Results: One hundred six women underwent mastectomy with immediate (n = 30) and delayed breast reconstruction (n = 76). Before reconstruction, 26 percent of patients had abnormal anxiety scores and 9 percent had abnormal depression scores, with no significant differences between groups. Patients awaiting delayed breast reconstruction had significantly impaired prereconstruction body image (p = 0.01) and sexuality (p = 0.01) and worse satisfaction with breast (p < 0.01), psychological (p < 0.01), and sexual well-being (p < 0.01). At 18 months after immediate and delayed breast reconstruction, there was significant improvement in anxiety, depression, body image, sexuality, and health-related quality of life. Conclusions: This single-center study shows that mastectomy with immediate breast reconstruction may protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with those waiting for delayed breast reconstruction. In patients who are oncologically eligible and strongly interested in breast reconstruction, efforts should be made to provide immediate breast reconstruction to decrease the interval of psychosocial distress, poor body image, and impaired sexuality.
Current Concepts in Debridement: Science and Strategies
Current Concepts in Debridement: Science and Strategies
Anghel, E et al
Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3S - p 82S–93S
Background: The establishment of a healthy wound bed through adequate debridement of infected, senescent, and/or devitalized tissue is central to the progression of normal wound healing. Although a variety of surgical and nonsurgical strategies have been proposed, none have proven completely effective in all settings. This review focuses on the principles and techniques of modern debridement practices employed in the management of complex wounds.
Methods: A comprehensive review of the PubMed/Medline and Ovid databases was performed to identify basic science and clinical studies using key words most relevant to biofilm, debridement, and wound healing. English language articles that were peer reviewed and that met the standard of evidence-based medicine were included. Level of evidence for various debridement approaches was rated utilizing the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations.
Results: The value of both operative and nonoperative debridement techniques, their indications, and limitations are described. With an emphasis placed on surgical debridement, this review highlights technical adjuncts that can be used to optimize wound bed preparation, including preoperative topical staining of the wound, as well as the use of color-guided endpoints to prevent removal of excess healthy tissue. The indications for using temporizing measures for wound control such as negative pressure wound therapy with and without installation are also discussed.
Conclusion: Optimal management requires a multimodal approach that centers around operative debridement and incorporates the use of adjunctive measures to facilitate the removal of infected tissue, biofilm, and/or senescent cells that impede the progression of normal wound healing.
Anghel, E et al
Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3S - p 82S–93S
Background: The establishment of a healthy wound bed through adequate debridement of infected, senescent, and/or devitalized tissue is central to the progression of normal wound healing. Although a variety of surgical and nonsurgical strategies have been proposed, none have proven completely effective in all settings. This review focuses on the principles and techniques of modern debridement practices employed in the management of complex wounds.
Methods: A comprehensive review of the PubMed/Medline and Ovid databases was performed to identify basic science and clinical studies using key words most relevant to biofilm, debridement, and wound healing. English language articles that were peer reviewed and that met the standard of evidence-based medicine were included. Level of evidence for various debridement approaches was rated utilizing the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations.
Results: The value of both operative and nonoperative debridement techniques, their indications, and limitations are described. With an emphasis placed on surgical debridement, this review highlights technical adjuncts that can be used to optimize wound bed preparation, including preoperative topical staining of the wound, as well as the use of color-guided endpoints to prevent removal of excess healthy tissue. The indications for using temporizing measures for wound control such as negative pressure wound therapy with and without installation are also discussed.
Conclusion: Optimal management requires a multimodal approach that centers around operative debridement and incorporates the use of adjunctive measures to facilitate the removal of infected tissue, biofilm, and/or senescent cells that impede the progression of normal wound healing.
Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry
Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry
Unger J et al
Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3 - p 548–555
Background: Implant-based breast reconstruction is performed with both saline and silicone. In 2001, a study was conducted in which a novel implant made of highly cohesive silicone gel in anatomical shape was used. It differs from others because it holds its anatomical shape and forces tissue to conform to the implant.
Methods: Two hundred twelve consecutive patients who underwent reconstruction with Allergan 410 cohesive gel anatomical implants were enrolled prospectively over a 12-year period. Complications and satisfaction rates were recorded.
Results: Average age of the patients was 48.5 years and average body mass index was 24.1 kg/m2. Bilateral reconstruction was performed in 83 percent of patients. Long-term follow-up was achieved in all patients and averaged 3.3 years (range, 0.5 to 10.2 years). The overall complication rate was 19.8 percent; most were minor complications, such as rippling (9.4 percent) and asymmetry (4.2 percent). Major complications included infection (2.4 percent), malposition (1.4 percent), capsular contracture (0.9 percent), seroma (0.5 percent), extrusion (0.5 percent), and implant rupture (0.5 percent). The rate of implant-related reoperation, excluding cancer recurrence, was 9.0 percent, consisting of implant replacement (5.7 percent), implant removal (1.9 percent), and implant repositioning (1.4 percent). Patient satisfaction averaged 4.83 (range, 2 to 5) on a five-point scale. Surgeon satisfaction averaged 4.9 (range, 2 to 5).
Conclusions: Allergan 410 cohesive gel anatomical implants have a favorable risk profile in reconstruction, with excellent patient and surgeon satisfaction. This novel implant allows for a paradigm shift in implant-based breast reconstruction. Surgeons can now use an implant to help shape the final contour of the breast mound rather than rely on mastectomy flaps and suture techniques to create aesthetic contours needed to create an attractive breast reconstruction.
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