Lower Extremity Free Flaps for Breast Reconstruction

Lower Extremity Free Flaps for Breast Reconstruction

Dayan, JH. Allen, RJ. 
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 77S–86S

Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient’s fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

Prepectoral Breast Reconstruction

Prepectoral Breast Reconstruction

Ter Louw, R P.  Nahabedian, M Y. 
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 51S–59S

Oncologic and reconstructive advancements in the management of patients with breast cancer and at high risk for breast cancer have led to improved outcomes and decreased patient morbidity. Traditional methods for prosthetic breast reconstructions have utilized total or partial muscle coverage of prosthetic devices. Although effective, placement of devices under the pectoralis major muscle can be associated with increased pain due to muscle spasm and animation deformities. Prepectoral prosthetic breast reconstruction has gained popularity in the plastic surgery community, and long-term outcomes have become available. This article will review the indications, technique, and current literature surrounding prepectoral prosthetic breast reconstruction.

Breast Reconstruction and Radiation Therapy: An Update

Breast Reconstruction and Radiation Therapy: An Update

Nelson, JA. Disa, JJ.
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 60S–68S

With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Katzel, EB.Bucky, LP. 

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 69S–76S

Summary: This article is a review of fat grafting for breast reconstruction. The use of small volume fat grafting for the correction of step-off deformities, intrinsic deformities, and extrinsic deformities of the breast, and the uses of large volume fat grafting for total breast reconstruction, correction of implant complications with simultaneous implant exchange with fat, and correction of noncancer chest wall deformities is reviewed. Cancer monitoring and the risks of cancer recurrence following fat-grafting to the breast is also reviewed.

Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Colwell, AS.Christensen, JM.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 7S–13S

Breast reconstruction following mastectomy has evolved to preserve the native skin and nipple of the breast and create a natural-appearing reconstruction in 1 or 2 surgeries. Nipple-sparing procedures appear to be oncologically safe with low risks of cancer recurrence. In our series of 2,182 nipple-sparing mastectomies, there was no development or recurrence of cancer in the nipple. Direct-to-implant single-stage surgery offers the patient a complete reconstruction at the time of mastectomy. Patient selection centers on preoperative breast anatomy combined with postoperative goals for size and uplift of the breast. The best candidates for nipple-sparing mastectomy and direct-to-implant breast reconstruction include those with grade I–II breast ptosis and those desiring to stay approximately the same breast size. The choice of incision and width of the implant play key roles in nipple centralization. Partial muscle coverage with acellular dermal matrix remains the most common technique to support the implant and offers the advantage of more soft-tissue coverage in the upper pole. With experience, complications and revisions are similar in this approach compared with more traditional 2-stage tissue expander-implant reconstruction. Thus, nipple-sparing mastectomy and direct-to-implant breast reconstruction is emerging as a preferred method of breast reconstruction when the breast skin envelope is sufficiently perfused.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Losken, A et al

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 14S–22S

The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Current Trends in Postmastectomy Breast Reconstruction

Current Trends in Postmastectomy Breast Reconstruction

Panchal, H. Matros, E.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 7S–13S

Postmastectomy immediate breast reconstruction in the U.S. continues to experience an upward trend owing to heightened awareness, innovations in reconstructive technique, growing evidence of improved patient-reported outcomes, and shifts in mastectomy patterns. Women with unilateral breast cancer are increasingly electing to undergo contralateral prophylactic mastectomy, instead of unilateral mastectomy or opting for breast conservation. The ascent in prophylactic surgeries correlates temporally to a shift toward prosthetic methods of reconstruction as the most common technique. Factors associated with the choice for implants include younger age, quicker recovery time, along with documented safety and enhanced aesthetic outcomes with newer generations of devices. Despite advances in autologous transfer, its growth is constrained by the greater technical expertise required to complete microsurgical transfer and potential barriers such as poor relative reimbursement. The increased use of radiation as an adjuvant treatment for management of breast cancer has created additional challenges for plastic surgeons who need to consider the optimal timing and method of breast reconstruction to perform in these patients.

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

Kim, J et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 30S–43S

Of the nearly 90,000 implant-based breast reconstructions performed in the United States, the majority use internal soft-tissue support. Aesthetically, these constructs may allow for better positioning of prosthesis, improve lower pole expansion, and increase projection. They may have particular utility in direct-to-implant, nipple-sparing mastectomies, and prepectoral reconstructions. In recent years, new permutations of acellular dermal matrices have evolved with diverse shapes, sizes, form-factor innovations, and processing characteristics. The literature is largely limited to retrospective studies (and meta-analyses thereof), making robust comparisons of 1 iteration vis-à-vis another difficult. Although synthetic mesh may provide a cost-effective alternative in primary and secondary reconstruction, comparative studies with acellular dermal matrix are lacking. This review aims to provide a balanced overview of recent biologic and synthetic mesh innovation. As this technology (and concomitant techniques) evolve, the reconstructive surgeon is afforded more—and better—choices to improve care for patients.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Lee, B et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5 - p 651e–664e

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient’s preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon’s technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Trends and predictions to 2020 in breast cancer mortality in Europe

Trends and predictions to 2020 in breast cancer mortality in Europe
Carioli G et al
The Breast, Article in Press

We analyzed trends in mortality from breast cancer in women in 36 European countries and the European Union (EU) over the period 1970–2014, and predicted numbers of deaths and rates to 2020.

Highlights:

• EU breast cancer mortality rates declined by 15% between 2002 and 2012.
• We predict a further 10% decline in breast cancer mortality to 2020.
• The falls were largest in the young.
• Trends were less favourable in central and eastern than in western Europe.
• The key determinant of the falls is management; early diagnosis contributed, too.

Breast Cancer Genetics for Plastic Surgeons

Breast Cancer Genetics for Plastic Surgeons
McInerney, N et al

Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 455–460

Summary: Multidisciplinary genetic clinics offer counseling and testing to those who meet criteria for familial breast cancer, and plastic surgeons become integral to this process when risk-reducing surgery and postmastectomy reconstruction are deemed appropriate. As reconstructive surgeons, it is important that plastic surgeons are aware of the risks and issues associated with the genetic variants that cause patients to present for prophylactic or therapeutic surgery.

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes
Cohen, O et al
Plastic and Reconstructive Surgery, September 2017 - Volume 140 - Issue 3 - p 382e–392e

Background: The increasing use of autologous fat grafting in breast cancer patients has raised concerns regarding its oncologic safety. This study evaluated patient outcomes and tumor recurrence following mastectomy reconstruction and autologous fat grafting. 
Methods: Retrospective chart review identified patients who underwent mastectomy followed by breast reconstruction from 2010 to 2015. Eight hundred twenty-nine breasts met inclusion criteria: 248 (30.0 percent) underwent autologous fat grafting, whereas 581 (70.0 percent) breasts did not. Patient demographics, cancer characteristics, oncologic treatment, surgical treatment, surgical complications, local recurrence, and distant metastases were analyzed. 
Results: Autologous fat grafting patients and control patients were of similar body mass index, smoking status, and BRCA status. Patients who underwent fat grafting were significantly younger than control patients and were less likely to have diabetes, hypertension, or hyperlipidemia. The two groups represented similar distributions of BRCA status, Oncotype scores, and hormone receptor status. Patients underwent one to four grafting procedures: one procedure in 83.1 percent, two procedures in 13.7 percent, three in 2.8 percent, and four in 0.4 percent. Mean follow-up time from initial surgery was 45.6 months in the fat grafting group and 38.8 months in controls. The overall complication rate following fat grafting was 9.4 percent. Among breasts undergoing surgery for therapeutic indications, there were similar rates of local recurrence (fat grafting group, 2.5 percent; controls, 1.9 percent; p = 0.747). Interestingly, mean time to recurrence was significantly longer in the fat grafting group (52.3 months versus 22.8 months from initial surgery; p = 0.016). 
Conclusions: Autologous fat grafting is a powerful tool in breast reconstruction. This large, single-institution study provides valuable evidence-based support for its oncologic safety. 

Five-Year Safety Data for More than 55,000 Subjects following Breast Implantation: Comparison of Rare Adverse Event Rates with Silicone Implants versus National Norms and Saline Implants

Five-Year Safety Data for More than 55,000 Subjects following Breast Implantation: Comparison of Rare Adverse Event Rates with Silicone Implants versus National Norms and Saline Implants
Singh, N et al
Plastic and  Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 666–679

Background: The U.S. Food and Drug Administration has required postapproval studies of silicone breast implants to evaluate the incidence of rare adverse events over 10 years after implantation. Methods: The Breast Implant Follow-Up Study is a large 10-year study (>1000 U.S. sites) evaluating long-term safety following primary augmentation, revision-augmentation, primary reconstruction, or revision-reconstruction with Natrelle round silicone breast implants compared with national norms and outcomes with saline implants. Targeted adverse events in subjects followed for 5 to 8 years included connective tissue diseases, neurologic diseases, cancer, and suicide. 
Results: The safety population comprised 55,279 women (primary augmentation, n = 42,873; revision-augmentation, n = 6837; primary reconstruction, n = 4828; and revision-reconstruction, n = 741). No targeted adverse events occurred at significantly greater rates in silicone implant groups versus national norms across all indications. The standardized incidence rate (observed/national norm) for all indications combined was 1.4 for cervical/vulvar cancer, 0.8 for brain cancer, 0.3 for multiple sclerosis, and 0.1 for lupus/lupus-like syndrome. Silicone implants did not significantly increase the risk for any targeted adverse events compared with saline implants. The risk of death was similar with silicone versus saline implants across all indications. The suicide rate (10.6 events per 100,000 person-years) was not significantly higher than the national norm. No implant-related deaths occurred. 
Conclusions: Results from 5 to 8 years of follow-up for a large number of subjects confirmed the safety of Natrelle round silicone implants, with no increased risk of systemic disease or suicide versus national norms or saline implants.

Breast Implant–Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand: High-Surface-Area Textured Implants Are Associated with Increased Risk

Breast Implant–Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand: High-Surface-Area Textured Implants Are Associated with Increased Risk
Loch-Wilkinson, A et al
Plastic and  Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 645–654

Background: The association between breast implants and breast implant–associated anaplastic large cell lymphoma (ALCL) has been confirmed. Implant-related risk has been difficult to estimate to date due to incomplete datasets. 
Methods: All cases in Australia and New Zealand were identified and analyzed. Textured implants reported in this group were subjected to surface area analysis. Sales data from three leading breast implant manufacturers (i.e., Mentor, Allergan, and Silimed) dating back to 1999 were secured to estimate implant-specific risk. 
Results: Fifty-five cases of breast implant–associated ALCL were diagnosed in Australia and New Zealand between 2007 and 2016. The mean age of patients was 47.1 years and the mean time of implant exposure was 7.46 years. There were four deaths in the series related to mass and/or metastatic presentation. All patients were exposed to textured implants. Surface area analysis confirmed that higher surface area was associated with 64 of the 75 implants used (85.3 percent). Biocell salt loss textured (Allergan, Inamed, and McGhan) implants accounted for 58.7 percent of the implants used in this series. Comparative analysis showed the risk of developing breast implant–associated ALCL to be 14.11 times higher with Biocell textured implants and 10.84 higher with polyurethane (Silimed) textured implants compared with Siltex textured implants. 
Conclusions: This study has calculated implant-specific risk of breast implant–associated ALCL. Higher-surface-area textured implants have been shown to significantly increase the risk of breast implant–associated ALCL in Australia and New Zealand. The authors present a unifying hypothesis to explain these observations.

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile

Mirzabeigi, M N et al
Plastic and Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 372e–381e

Background: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. 
Methods: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. 
Results: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. Conclusion: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.

Contralateral Prophylactic Mastectomy

Contralateral Prophylactic Mastectomy

Ramaswami R
New England Journal of Medicine, Volume 377, Issue 13, Page 1288-1291, September 2017.

CASE VIGNETTE
A Woman Considering Contralateral Prophylactic Mastectomy

A 51-year-old woman who has recently received a diagnosis of breast cancer, and she comes to you to seek your opinion about her surgical options. Three weeks earlier, she had undergone mammography and magnetic resonance imaging to evaluate a mass in the left breast. She has been told that she has a 3-cm triple-negative (i.e., negative for estrogen and progesterone receptors and for overexpression of human epidermal growth factor receptor type 2 [HER2]) invasive ductal carcinoma of the left breast. The breast cancer is at clinical stage IIA or T2N0M0 .......

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions
Merkkola-von Schantzet, P A al
The Breast October 2017 Volume 35, Pages 157–161

Contralateral reduction mammaplasty is regularly included in the treatment of breast cancer patients. We analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens of women with previous breast cancer. We also analyzed if timing of reduction mammaplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics.

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire
Mylvaganam S et al
The Breast October 2017Volume 35, Pages 182–190

The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.

Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer

Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer
Zingarello A et al
The Breast October 2017 Volume 35, Pages 162–168

The rate of local recurrences, after breast-conserving surgery or mastectomy for hormone receptor-positive (HR+) breast cancer, has dramatically changed in last decades, due to advances in surgical and radiation techniques and a more extensive use of adjuvant systemic treatments. However, the occurrence of local recurrences remains a major predictor for distant metastasis and is responsible for increased cancer-specific death. It has been estimated that 1 in 4 HR+ and HR-ipsilateral breast recurrences leads to widespread metastatic disease, with an annual mortality rate of 10% in the first 5 years.

Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review

Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review
Toss M et al
The Breast October 2017 Volume 35, Pages 151–156

The high proportion of ductal carcinoma in situ (DCIS) presented in mammographic screening and the relatively low risk of progression to invasive disease have raised questions related to overtreatment. Following a review of current DCIS management protocols a more conservative approach has been suggested. Clinical trials have been introduced to evaluate the option of avoiding surgical intervention in a proportion of patients with DCIS defined as “low-risk” using certain clinicopathological criteria.

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes
Cohen, O et al

Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 382e–392e

Background: The increasing use of autologous fat grafting in breast cancer patients has raised concerns regarding its oncologic safety. This study evaluated patient outcomes and tumor recurrence following mastectomy reconstruction and autologous fat grafting. 

Methods: Retrospective chart review identified patients who underwent mastectomy followed by breast reconstruction from 2010 to 2015. Eight hundred twenty-nine breasts met inclusion criteria: 248 (30.0 percent) underwent autologous fat grafting, whereas 581 (70.0 percent) breasts did not. Patient demographics, cancer characteristics, oncologic treatment, surgical treatment, surgical complications, local recurrence, and distant metastases were analyzed. 
Results: Autologous fat grafting patients and control patients were of similar body mass index, smoking status, and BRCA status. Patients who underwent fat grafting were significantly younger than control patients and were less likely to have diabetes, hypertension, or hyperlipidemia. The two groups represented similar distributions of BRCA status, Oncotype scores, and hormone receptor status. Patients underwent one to four grafting procedures: one procedure in 83.1 percent, two procedures in 13.7 percent, three in 2.8 percent, and four in 0.4 percent. Mean follow-up time from initial surgery was 45.6 months in the fat grafting group and 38.8 months in controls. The overall complication rate following fat grafting was 9.4 percent. Among breasts undergoing surgery for therapeutic indications, there were similar rates of local recurrence (fat grafting group, 2.5 percent; controls, 1.9 percent; p = 0.747). Interestingly, mean time to recurrence was significantly longer in the fat grafting group (52.3 months versus 22.8 months from initial surgery; p = 0.016). 
Conclusions: Autologous fat grafting is a powerful tool in breast reconstruction. This large, single-institution study provides valuable evidence-based support for its oncologic safety.

Surgical Indications and Outcomes of Mastectomy in Transmen: A Prospective Study of Technical and Self-Reported Measures

Surgical Indications and Outcomes of Mastectomy in Transmen: A Prospective Study of Technical and Self-Reported Measures
van de Grift, T C et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 415e–424e

Background: Although transgender surgery constitutes a growing field within plastic surgery, prospective studies on masculinizing mastectomies are lacking. The objectives of the present study were to prospectively follow a cohort of transmen undergoing mastectomy to assess technical and self-reported outcomes and to evaluate surgical decision-making.
Methods: Fifty-four transmen were recruited during a 10-month period at the Department of Plastic Surgery of the Centre of Expertise on Gender Dysphoria. Preoperative assessment included standardized chest examination. Six months postoperatively, participants rated their satisfaction with surgery, and 12-month postoperative surgical outcomes were reviewed independently. Surgical decision-making was evaluated by comparing indications and outcomes per technique, and assessing the clinical validity of the most-used decision aid (using the Cohen's kappa statistic).
Results: One periareolar mastectomy, 26 concentric circular mastectomies, and 22 inframammary skin resections with free nipple graft were performed in the authors’ cohort. Five participants were still to be operated on. Concentric circular mastectomy was performed in smaller or medium-size breasts with low ptosis grade and good elasticity, whereas the inframammary skin resection group showed a wider range of physical characteristics. Despite being performed in better quality breasts, concentric circular mastectomy was associated with more secondary corrections (38.5 percent), dehiscence, seroma, and lower postoperative satisfaction compared with inframammary skin resections. Clinical decision-making was generally in line with the published decision aid. Conclusions: Compared with inframammary skin resections, concentric circular mastectomy—despite being performed in favorable breast types—appears to produce poorer technical and self-reported outcomes. Surgical indications and preoperative counseling regarding secondary corrections may therefore be subject to improvement.

Autologous Fat Grafting as a Novel Antiestrogen Vehicle for the Treatment of Breast Cancer

Autologous Fat Grafting as a Novel Antiestrogen Vehicle for the Treatment of Breast Cancer
Thomas, S et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 537–544
Background: Adipose fat transfer is increasingly used for contour corrections of the tumor bed after lumpectomy and breast reconstructions after mastectomy. The lipophilic nature of the fat tissue may render adipocytes an ideal vehicle with which to deliver a high boost of an antiestrogen to the tumor bed to serve as an adjunct systemic hormonal therapy. The authors therefore tested whether adipocytes could safely be loaded with an antiestrogen and allow for release at therapeutic concentrations to treat breast cancer. 
Methods: Adipose tissue was collected from patients undergoing autologous fat grafting. The influence of adipose tissue on tumorigenesis was determined both in vitro and in vivo using breast cancer cell lines. Ex vivo, adipose tissue was assessed for its ability to depot fulvestrant and inhibit the growth of breast cancer cell lines. 
Results: Adipose tissue harvested from patients did not promote breast cancer cell growth in vitro or in an in vivo mouse model. Adipose tissue was successfully loaded with fulvestrant and released at levels sufficient to inhibit estrogen receptor signaling and growth of breast cancer cells. 
Conclusions: This work supports the hypothesis that adipose tissue used for autologous fat grafting can serve as a novel method for local drug delivery. As this technique is used to reconstruct a variety of postsurgical defects following cancer resection, this approach for local drug delivery may be an effective alternative in therapeutic settings beyond breast cancer.

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?
Gunnarsson, G L et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 449–454

Background: Nipple-sparing mastectomy with simultaneous hammock technique direct-to-implant reconstruction is increasingly offered to patients opting for risk-reducing mastectomy. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat satisfactorily and more often end up undergoing a difficult corrective procedure and experience an unacceptably high rate of failed reconstruction. The authors examined whether targeted preshaping mastopexy/reduction could prepare these patients for a successful nipple-sparing mastectomy/direct-to-implant reconstruction. 

Methods: Patients seeking risk-reducing nipple-sparing mastectomy/direct-to-implant reconstruction at the authors’ institutions deemed unfit for a one-stage procedure based on their previous experience were offered a targeted two-stage, risk-reducing mastopexy/reduction followed by a delayed secondary nipple-sparing mastectomy and direct-to-implant reconstruction. Patients were followed up at 3 weeks and 6 or 12 months. 
Results: Forty-four reconstructions were performed in 22 patients aged 43 years (range, 26 to 57 years). All 44 procedures were completed successfully without any failure or nipple-areola complex losses. Patients’ median body mass index was 30 kg/m2 (range, 22 to 44 kg/m2). Six patients were smokers and one had hypertension. Two patients underwent reoperation because of hematoma and fat necrosis. 
Conclusions: The authors’ results demonstrate that a targeted preshaping mastopexy/reduction followed by nipple-sparing mastectomy/direct-to-implant reconstruction can be safely planned in women who opt for a risk-reducing mastectomy and can be performed successfully with a 3- to 4-month time span between operations. On the basis of these results and the superior cosmetic outcome, the two-stage approach has become the authors' standard of care in all such settings. 

Macrotextured Breast Implants with Defined Steps to Minimize Bacterial Contamination around the Device: Experience in 42,000 Implants

Macrotextured Breast Implants with Defined Steps to Minimize Bacterial Contamination around the Device: Experience in 42,000 Implants
Adams, W P et al
Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 427–431

Background: Bacteria/biofilm on breast implant surfaces has been implicated in capsular contracture and breast implant–associated anaplastic large-cell lymphoma (ALCL). Macrotextured breast implants have been shown to harbor more bacteria than smooth or microtextured implants. Recent reports also suggest that macrotextured implants are associated with a significantly higher incidence of breast implant–associated ALCL. Using techniques to reduce the number of bacteria around implants, specifically, the 14-point plan, has successfully minimized the occurrence of capsular contracture. The authors hypothesize that a similar effect may be seen in reducing the risk of breast implant–associated ALCL. 
Methods: Pooled data from eight plastic surgeons assessed the use of macrotextured breast implants (Biocell and polyurethane) and known cases of breast implant–associated ALCL. Surgeon adherence to the 14-point plan was also analyzed. 
Results: A total of 42,035 Biocell implants were placed in 21,650 patients; mean follow-up was 11.7 years (range, 1 to 14 years). A total of 704 polyurethane implants were used, with a mean follow-up of 8.0 years (range, 1 to 20 years). The overall capsular contracture rate was 2.2 percent. There were no cases of implant–associated ALCL. All surgeons routinely performed all 13 perioperative components of the 14-point plan; two surgeons do not routinely prescribe prophylaxis for subsequent unrelated procedures. 
Conclusions: Mounting evidence implicates the role of a sustained T-cell response to implant bacteria/biofilm in the development of breast implant–associated ALCL. Using the principles of the 14-point plan to minimize bacterial load at the time of surgery, the development and subsequent sequelae of capsular contracture and breast implant–associated ALCL may be reduced, especially with higher-risk macrotextured implants. 

Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy

Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy
Sbitany, H et al

Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 432–443

Background: Nipple-sparing mastectomy with immediate prosthetic reconstruction is routinely performed because of excellent aesthetic results and safe oncologic outcomes. Typically, subpectoral expanders are placed, but in select patients, this can lead to significant postoperative pain and animation deformity, caused by pectoralis major muscle disinsertion and stretch. Prepectoral reconstruction is a technique that eliminates dissection of the pectoralis major by placing the prosthesis completely above the muscle with complete acellular dermal matrix coverage. 
Methods: A single surgeon’s experience with immediate prosthetic reconstruction following nipple-sparing mastectomy from 2012 to 2016 was reviewed. Patient demographics, adjuvant treatment, length and characteristics of the expansion, and incidence of complications during the tissue expander stage were compared between the partial submuscular/partial acellular dermal matrix (dual-plane) cohort and the prepectoral cohort. 
Results: Fifty-one patients (84 breasts) underwent immediate prepectoral tissue expander placement, compared with 115 patients (186 breasts) undergoing immediate partial submuscular expander placement. The groups had similar comorbidities and postoperative radiation exposure. There was no significant difference in overall complication rate between the two groups (17.9 percent versus 18.8 percent; p = 0.49). 
Conclusions: Prepectoral breast reconstruction provides a safe and effective alternative to partial submuscular reconstruction, that yields comparable aesthetic results with less operative morbidity. In the authors’ experience, the incidence of acute and chronic postoperative pain and animation deformity is significantly lower following prepectoral breast reconstruction. This technique is now considered for all patients who are safe oncologic candidates and are undergoing nipple-sparing mastectomy and prosthetic reconstruction. 

Oncoplastic breast surgery: comprehensive review.

Oncoplastic breast surgery: comprehensive review.


Bertozzi, N et al

European review for medical and pharmacological sciences; Jun 2017; vol. 21 (no. 11); p. 2572-2585

Breast cancer is the most common female cancer in Western populations, affecting 12.5% of women, with 1.38 million patients per year. Breast-conserving surgery followed by postoperative radiotherapy replaced the radical and modified-radical procedures of Halsted and Patey as the standard of care for early-stage breast cancer once the overall and disease-free survival rates of breast-conserving surgery were demonstrated to be equivalent to those of mastectomy. However, excision of >20% of breast tissue, low or centrally located cancer, and large-sized breasts with various grades of breast ptosis, result a in unacceptable cosmetic outcomes. Oncoplastic breast surgery evolved from the breast-conserving surgery by broadening its general indication to achieve wider excision margins without compromising on the cosmetic outcomes....

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement

A step-by-step oncoplastic breast conservation surgical atlas of reproducible dissection techniques and anatomically ideal incision placement

Mitchell, SD

Breast cancer research and treatment; Jun 2017

PURPOSE To develop an atlas for oncoplastic surgery (OPS) with template dissection techniques via anatomically ideal incisions for breast conservation surgery. The evolution of breast conservation techniques has evolved from placing an incision directly over the lesion to the incorporation of a thoughtful decision making process utilizing oncoplastic surgical (OPS) techniques to combining OPS with incision placement in anatomically advantageous sites. The high survival rates of breast cancer and effect of breast surgery on quality of life reinforce emphasis of optimal oncologic as well as aesthetic outcome. OPS results in greater patient satisfaction, fewer surgeries, and is oncologically safe. Today's breast surgeon is tasked with optimizing both oncologic and aesthetic outcomes.METHODSPresentation of reproducible dissection techniques and incision placement strategies to afford surgeons a step-by-step approach of OPS via anatomically ideal incisions in breast conservation surgery.RESULTSDemonstration of reproducible techniques to facilitate the decision making process of optimal breast conservation surgery, eliminate knowledge gaps for surgeons, optimize outcome for individuals undergoing breast conservation surgery, and decrease disparity of care.CONCLUSIONAdoption of OPS techniques utilizing an anatomically ideal incision in breast conservation surgery is a feasible and reproducible practice for breast surgeons. Application of these techniques results in maintained optimal shape, size, and contour without the typical overlying skin envelope scars. OPS techniques performed under the skin envelope result in expected OPS oncologic and aesthetic outcomes with the addition of the resulting scar(s) in anatomically discrete position(s).

Evidence-Based Medicine: Alloplastic Breast Reconstruction

Evidence-Based Medicine: Alloplastic Breast Reconstruction

Lennox, PA et al
Plastic & Reconstructive Surgery: July 2017 - Volume 140 - Issue 1 - p 94e–108e


Learning Objectives: After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction. 
Summary: There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Tumor-to-Nipple Distance as a Predictor of Nipple Involvement: Expanding the Inclusion Criteria for Nipple-Sparing Mastectomy

Tumor-to-Nipple Distance as a Predictor of Nipple Involvement: Expanding the Inclusion Criteria for Nipple-Sparing Mastectomy

Dent, BL et al
Plastic & Reconstructive Surgery: July 2017 - Volume 140 - Issue 1 - p 1e–8e

Background: A tumor-to-nipple distance of greater than 2 cm has traditionally been considered a criterion for nipple-sparing mastectomy. This study evaluates whether magnetic resonance imaging and sonographic measurements of tumor-to-nipple distance accurately reflect the risk of nipple involvement by disease. 
Methods: All nipple-sparing mastectomy cases with implant-based reconstruction performed by the senior author between July 2006 and December 2014 were retrospectively reviewed. Therapeutic cases with preoperative magnetic resonance imaging or sonography were included. Results: One hundred ninety-five cases were included. Preoperative imaging consisted of sonography (n = 169), magnetic resonance imaging (n = 152), or both (n = 126). With sonography, nipple involvement did not differ between nipple-sparing mastectomy candidates and noncandidates using a tumor-to-nipple distance cutoff of 2 cm (10.7 percent versus 10.6 percent; p = 0.988) or 1 cm (9.3 percent versus 15.0 percent; p = 0.307). With magnetic resonance imaging, nipple involvement did not differ between candidates and noncandidates using a cutoff of 2 cm (11.6 percent versus 12.5 percent; p = 0.881) or 1 cm (11.4 percent versus 13.8 percent; p = 0.718). When sonography and magnetic resonance imaging findings were both available and concordant, nipple involvement still did not differ between candidates and noncandidates using a cutoff of 2 cm (8.8 percent versus 11.8 percent; p = 0.711) or 1 cm (7.6 percent versus 14.3 percent; p = 0.535). 
Conclusion: A tumor-to-nipple distance as small as 1 cm, as measured by sonography or magnetic resonance imaging, should not be considered a contraindication to nipple-sparing mastectomy. 

Current standards in oncoplastic breast conserving surgery

Current standards in oncoplastic breast conserving surgery

Weber, WP et al
The Breast : Article in Press

Oncoplastic breast conserving surgery is increasingly used to treat patients with breast cancer. In the absence of randomized data, a large body of observational evidence consistently indicates low rates of recurrence and high rates of survival, but points to a higher rate of complications compared to conventional breast conserving surgery. Established goals of oncoplastic breast conserving surgery are to broaden the indication for breast conservation towards larger tumors, and to improve esthetic outcomes.

Rationale for immunological approaches to breast cancer therapy

Rationale for immunological approaches to breast cancer therapy

Monnot GC and Romero P
The Breast 
Article in Press

Despite great advances in early detection, as well as surgical resection of breast tumours, breast cancer remains the deadliest cancer for women worldwide. Moreover, its incidence is without pair, accounting for twice as many new cancer cases as the second most prevalent cancer, colorectal carcinoma. There is therefore a strong need for new therapeutic approaches to breast cancers. Immunotherapies are novel treatment modalities which aim to use immune mediators to attack cancerous cells. Recent clinical results show that these may not only mediate tumour regressions but also cures in some cases.

Evaluation of margins in invasive carcinoma and ductal carcinoma in situ: The pathologist's perspective

Evaluation of margins in invasive carcinoma and ductal carcinoma in situ: The pathologist's perspective

Schnitt SJ
The Breast 
Article in Press

A variety of patient factors, treatment factors and pathologic factors are associated with an increased risk of ipsilateral breast tumor recurrence (local recurrence) after breast conservation therapy for invasive breast cancer and ductal carcinoma in situ (DCIS). Arguably, the most important of these is the status of the microscopic margins of excision of the resected breast specimen. Until recently there has been no agreement on what constitutes an adequate negative lumpectomy margin for patients with either invasive breast cancer or DCIS managed with the breast conserving approach  and this issue has never been addressed in randomized clinical trials.

Postoperative radiotherapy after DCIS: Useful for whom?

Postoperative radiotherapy after DCIS: Useful for whom?

Karlsson P
The Breast 
Article in Press

The number of patients with ductal carcinoma in situ (DCIS) increases with more widely used screening mammography programs. DCIS accounts for approximately 20% of all new breast cancer diagnoses in these programs and the natural course of this heterogeneous group of pre-invasive lesions is not fully known. Better definition of subgroups benefitting from radiotherapy and knowledge on the natural course of DCIS are important issues for the future management of DCIS.Four large randomized trials have studied the effects of postoperative radiotherapy after breast conserving surgery in patients with wider spectrum of DCIS and all of them have shown radiotherapy to halve the risk of ipsilateral events, however, without any significant effect on breast cancer mortality.

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction

Muresan, H et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1232e–1239e

Background: Patients undergoing implant-based reconstruction in the setting of postmastectomy radiation therapy suffer from increased complications and inferior outcomes compared with those not irradiated, but advances in radiation delivery have allowed for more nuanced therapy. The authors investigated whether these advances impact patient outcomes in implant-based breast reconstruction. 
Methods: Retrospective chart review identified all implant-based reconstructions performed at a single institution from November of 2010 to November of 2013. These data were cross-referenced with a registry of patients undergoing breast irradiation. Patient demographics, treatment characteristics, and outcomes were analyzed. 
Results: Three hundred twenty-six patients (533 reconstructions) were not irradiated, whereas 83 patients (125 reconstructions) received radiation therapy; mean follow-up was 24.7 months versus 26.0 months (p = 0.49). Overall complication rates were higher in the irradiated group (35.2 percent versus 14.4 percent; p < 0.01). Increased maximum radiation doses to the skin were associated with complications (maximum dose to skin, p = 0.05; maximum dose to 1 cc of skin, p = 0.01). Different treatment modalities (e.g., three-dimensional conformal, intensity-modulated, field-in-field, and hybrid techniques) did not impact complication rates. Prone versus supine positioning significantly decreased the maximum skin dose (58.5 Gy versus 61.7 Gy; p = 0.05), although this did not translate to significantly decreased complication rates in analysis of prone versus supine positioning. 
Conclusions: As radiation techniques evolve, the maximum dose to skin should be given consideration similar to that for heart and lung dosing, to optimize reconstructive outcomes. Prone positioning significantly decreases the maximum skin dose and trends toward significance in reducing reconstructive complications. With continued study, this may become clinically important. Interdepartmental studies such as this one ensure quality of care.

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Aliu, O et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1224e–1231e

Background: In the debate on reconstruction of the irradiated breast, there is little information on associated health care resource use. Nationwide data were used to examine health care resource use associated with implant and autologous reconstruction. It was hypothesized that failure rates would contribute the most to higher average cumulative cost with either reconstruction method. 
Methods: From the 2009 to 2013 MarketScan Commercial Claims and Encounters database, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected. In a 24-month follow-up period, the cumulative costs of health care services used were tallied and described. Regression models stratified by reconstruction method were then used to estimate the influence of failure on cumulative cost of reconstruction. 
Results: There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively. Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases. Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction. The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344. In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for autologous reconstruction. 
Conclusions: More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure. These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.

Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies

Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies

Frey, J et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1300–1310

Background: Nipple-sparing mastectomy permits complete preservation of the nipple-areola complex with excellent aesthetic results and with oncologic safety similar to that associated with traditional mastectomy techniques. However, outcomes have not been directly compared for tissue expander–, immediate implant–, and autologous tissue–based breast reconstruction after nipple-sparing mastectomy. Methods: All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified at a single institution. Demographics and outcomes were analyzed and compared among different types of breast reconstruction. Results: A total of 1028 nipple-sparing mastectomies were performed. Of these, 533 (51.8 percent) were tissue expander–based, 263 (25.6 percent) were autologous tissue–based, and 232 (22.6 percent) were immediate implant–based reconstructions. Tissue expander–based reconstructions had significantly more minor cellulitis (p = 0.0002) but less complete nipple necrosis (p = 0.0126) and major mastectomy flap necrosis (p < 0.0001) compared with autologous tissue–based reconstructions. Compared to immediate implant–based reconstruction, tissue expander–based reconstructions had significantly more minor cellulitis (p = 0.0006) but less complete nipple necrosis (p = 0.0005) and major (p < 0.0001) and minor (p = 0.0028) mastectomy flap necrosis (p = 0.0059). Immediate implant–based reconstructions had significantly more minor cellulitis (p = 0.0051), minor mastectomy flap necrosis (p = 0.0425), and partial nipple necrosis (p = 0.0437) compared with autologous tissue–based reconstructions. Outcomes were otherwise equivalent among the three groups. Conclusions: Tissue expander, immediate implant, and autologous tissue breast reconstruction techniques may all be safely offered with nipple-sparing mastectomy. However, reconstructive complications appear to be greater with immediate implant– and autologous tissue–based techniques compared with tissue expander–based reconstruction.

Is Rotation a Concern with Anatomical Breast Implants? A Statistical Analysis of Factors Predisposing to Rotation

Is Rotation a Concern with Anatomical Breast Implants? A Statistical Analysis of Factors Predisposing to Rotation

Montemurro, P et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1367–1378

Background: Since their introduction in 1993, anatomical implants have provided a more natural appearance in breast augmentation, and many surgeons advocate their use and promote the good aesthetic results. However, the risk of implant rotation makes some of them reluctant to use these devices. The rotation rate varies among authors. 
Methods: The authors present a 6.5-year series of 531 patients who underwent primary breast augmentation with macrotextured anatomical implants in a Swedish facility performed by one consultant surgeon (P.M.). The authors examined the rotation rate and the correlation with possible predisposing factors such as preoperative breast cup size, childbirth, and body mass index. 
Results: A total of 20 implants (1.88 percent; 95 percent CI, 1.15 to 2.89 percent) in 19 patients (3.58 percent; 95 percent CI, 2.17 to 5.53 percent) were rotated. In one patient (0.22 percent), both implants rotated, whereas in the remaining patients, the rotation was unilateral. The authors were unable to establish a statistically significant correlation between implant rotation and previous childbirth or increased body mass index. However, there was a relation between rotation rate and preoperative breast cup size that showed an upward trend as the cup size increased from A to C. 
Conclusion: The authors believe that if the implant is correctly selected and the operation is performed meticulously with proper pocket dissection, the rotation rate is minimal and it should not be considered a disadvantage for the use of anatomical implants.

Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes

Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes

Billig, J et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1279–1288

Background: In women who require postmastectomy radiation therapy, immediate autologous breast reconstruction is often discouraged. The authors prospectively evaluated postoperative morbidity and satisfaction reported by women undergoing delayed or immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy. 
Methods: Patients enrolled in the Mastectomy Reconstruction Outcomes Consortium study, who received postmastectomy radiotherapy and underwent immediate or delayed free abdominally based autologous breast reconstruction, were identified. Postoperative complications at 1 and 2 years after reconstruction were assessed. Patient-reported outcomes were evaluated using the BREAST-Q questionnaire preoperatively and at 1 and 2 years postoperatively. Bivariate analyses and mixed-effects regression models were used to compare outcomes. 
Results: A total of 175 patients met the authors’ inclusion criteria. Immediate reconstructions were performed in 108 patients and delayed reconstructions in 67 patients; 93.5 percent of immediate reconstructions were performed at a single center. Overall complication rates were similar based on reconstructive timing (25.9 percent immediate and 26.9 percent delayed at 1 year; p = 0.54). Patients with delayed reconstruction reported significantly lower prereconstruction scores (p < 0.0001) for Satisfaction with Breasts and Psychosocial and Sexual Well-being than did patients with immediate reconstruction. At 1 and 2 years postoperatively, both groups reported comparable levels of satisfaction in assessed BREAST-Q domains. 
Conclusions: From this prospective cohort, immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy appears to be a safe option that may be considered in select patients and centers. Breast aesthetics and quality of life, evaluated from the patient’s perspective, were not compromised by flap exposure to radiation therapy. 

Principles of Breast Re-Reduction: A Reappraisal

Principles of Breast Re-Reduction: A Reappraisal

Mistry, RM et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1313–1322

Background: This article examines outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Methods: A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Patient demographics, surgical technique, and outcomes were analyzed. Results: Ninety patients underwent breast re-reduction surgery. The average interval between primary and secondary surgery was 14 years (range, 0 to 42 years). The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 percent)]. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 percent)]. The nipple-areola complex was repositioned in 60 percent of patients (n = 54). The mean volume of tissue resected was 250 g (range, 22 to 758 g) from the right breast and 244 g (range, 15 to 705 g) from the left breast. Liposuction was also used adjunctively in all cases (average, 455 cc; range, 50 to 1750 cc). Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 percent). Conclusions: Breast re-reduction can be performed safely and predictably, even when the previous technique is not known. Four key principles were developed: (1) the nipple-areola complex can be elevated by deepithelialization rather than recreating or developing a new pedicle; (2) breast tissue is removed where it is in excess, usually inferiorly and laterally; (3) the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and (4) skin should not be excised horizontally below the inframammary fold. 

Fat Grafting after Invasive Breast Cancer: A Matched Case-Control Study

Fat Grafting after Invasive Breast Cancer: A Matched Case-Control Study

Petit, JY et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1292–1296

Background: Fat grafting has been widely indicated for postmastectomy and postlumpectomy breast reconstruction. The literature emphasizes the clinical efficacy of fat grafting, but experimental studies raise important questions about the recurrence risk because of the stimulation of remaining cancer cells by progenitor or adult adipocytes. Because breast conservative treatment provides a higher risk of residual cancer cells in the breast tissue compared with mastectomy, the authors set up a matched case-control study of fat grafting versus no fat grafting after breast conservative treatment. Methods: The authors collected data from 322 consecutive patients operated on for a primary invasive breast cancer who subsequently underwent fat grafting for breast reshaping from 2006 to 2013. All patients were free of recurrence before fat grafting. For each patient, the authors selected one patient with similar characteristics who did not undergo fat grafting. Results: After a mean follow-up of 4.6 years (range, 0.1 to 10.2 years) after fat grafting, or a corresponding time for controls, the authors observed no difference in the incidence of local events (fat grafting, n = 14; controls, n = 16; p = 0.49), axillary nodes metastasis (fat grafting, n = 3; controls, n = 6; p = 0.23), distant metastases (fat grafting, n = 14; controls, n = 15; p = 0.67), or contralateral breast cancer (fat grafting, n = 4; controls, n = 4; p = 0.51). Conclusion: Fat grafting seems to be a safe procedure after breast conservative treatment for breast cancer patients. 

Breast Cancer after Augmentation: Oncologic and Reconstructive Considerations among Women Undergoing Mastectomy

Breast Cancer after Augmentation: Oncologic and Reconstructive Considerations among Women Undergoing Mastectomy

Cho, E et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1240e–1249e

Background: Breast augmentation with subglandular versus subpectoral implants may differentially impact the early detection of breast cancer and treatment recommendations. The authors assessed the impact of prior augmentation on the diagnosis and management of breast cancer in women undergoing mastectomy. 
Methods: Breast cancer diagnosis and management were retrospectively analyzed in all women with prior augmentation undergoing therapeutic mastectomy at the authors’ institution from 1993 to 2014. Comparison was made to all women with no prior augmentation undergoing mastectomy in 2010. Subanalyses were performed according to prior implant placement. Results: A total of 260 women with (n = 89) and without (n = 171) prior augmentation underwent mastectomy for 95 and 179 breast cancers, respectively. Prior implant placement was subglandular (n = 27) or subpectoral (n = 63) (For five breasts, the placement was unknown). Breast cancer stage at diagnosis (p = 0.19) and detection method (p = 0.48) did not differ for women with and without prior augmentation. Compared to subpectoral augmentation, subglandular augmentation was associated with the diagnosis of invasive breast cancer rather than ductal carcinoma in situ (p = 0.01) and detection by self-palpation rather than screening mammography (p = 0.03). Immediate two-stage implant reconstruction was the preferred reconstructive method in women with augmentation (p < 0.01). 
Conclusions: Breast cancer stage at diagnosis was similar for women with and without prior augmentation. Among women with augmentation, however, subglandular implants were associated with more advanced breast tumors commonly detected on palpation rather than mammography. Increased vigilance in breast cancer screening is recommended among women with subglandular augmentation. 

Subfascial Primary Breast Augmentation with Fat Grafting: A Review of 156 Cases

Subfascial Primary Breast Augmentation with Fat Grafting: A Review of 156 Cases

Kerfant, N et al
Plastic & Reconstructive Surgery: May 2017 - Volume 139 - Issue 5 - p 1080e–1085e

Background: Composite breast augmentation with fat grafting and an implant has become very popular in the past 5 years. This achieves the core volume projection of an implant complemented by the natural appearance and feel of fat. However, no study has looked at the complications and reoperation rates of this technique. Methods: A retrospective chart review examined all patients who underwent the combined use of an implant and fat grafting for primary breast augmentation. Results: The study identified 156 patients between 2007 and 2013. The mean patient age was 31.7 years and the average body mass index was 18.85 kg/m2. The average implant size was 252 cc. Patients received a mean of 126 cc of fat (range, 30 to 250 cc) in subcutaneous soft tissue. Follow-up averaged 22.25 months (range, 1 to 86 months). The total complication rate was 7.7 percent and the reoperation rate was 9.94 percent. Baker grade II/III contracture was the most common complication [Baker grade II, n = 4 (2.56 percent); Baker grade III, n = 2 (2 percent)], followed by infections [n = 2 (1.28 percent)], hematoma [n = 2 (1.28 percent)], and malrotation [n = 1 (0.64 percent)]. Delayed reoperation was performed in nine patients (9.94 percent) after a mean interval of 31.7 months. Two patients who developed Baker grade III contractures needed surgery to correct the problem. Three cases (1.92 percent) required additional fat grafting for insufficient soft-tissue coverage. The mean volume of fat reinjection was 170 cc. Conclusions: Composite breast augmentation is a valuable, stable, reliable technique in breast aesthetic surgery with good, natural-appearing results. It provides long-term aesthetic benefits and avoids the submuscular plane.