Acellular Dermal Matrix in Immediate Expander/Implant Breast Reconstruction: A Multicenter Assessment of Risks and Benefits
Sorkin M et al
Plastic and Reconstructive Surgery: December 2017 - Volume 140 - Issue 6 - p 1091–1100
Background: Acellular dermal matrix has gained widespread acceptance in immediate expander/implant reconstruction because of perceived benefits, including improved expansion dynamics and superior aesthetic results. Although previous investigators have evaluated its risks, few studies have assessed the impact of acellular dermal matrix on other outcomes, including patient-reported measures. Methods: The Mastectomy Reconstruction Outcomes Consortium Study used a prospective cohort design to evaluate patients undergoing postmastectomy reconstruction from 10 centers and 58 participating surgeons between 2012 and 2015. The analysis focused on women undergoing immediate tissue expander reconstruction following mastectomies for cancer treatment or prophylaxis. Medical records and patient-reported outcome data, using the BREAST-Q and Numeric Pain Rating Scale instruments, were reviewed. Bivariate analyses and mixed-effects regression models were applied. Results: A total of 1297 patients were evaluated, including 655 (50.5 percent) with acellular dermal matrix and 642 (49.5 percent) without acellular dermal matrix. Controlling for demographic and clinical covariates, no significant differences were seen between acellular dermal matrix and non–acellular dermal matrix cohorts in overall complications (OR, 1.21; p = 0.263), major complications (OR, 1.43; p = 0.052), wound infections (OR, 1.49; p = 0.118), or reconstructive failures (OR, 1.55; p = 0.089) at 2 years after reconstruction. There were also no significant differences between the cohorts in the time to expander/implant exchange (p = 0.78). No significant differences were observed in patient-reported outcome scores, including satisfaction with breasts, psychosocial well-being, sexual well-being, physical well-being, and postoperative pain. Conclusions: In this multicenter, prospective analysis, the authors found no significant acellular dermal matrix effects on complications, time to exchange, or patient-reported outcome in immediate expander/implant breast reconstruction. Further studies are needed to develop criteria for more selective use of acellular dermal matrix in these patients.
Thursday, 11 January 2018
Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management
Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management
Perez J, Rohrich RJ
Plastic and Reconstructive Surgery: December 2017 - Volume 140 - Issue 6 - p 782e–793e
Background: Scar management is critical for every plastic surgeon’s practice and, ultimately, the patient’s satisfaction with his or her aesthetic result. Despite the critical nature of this component of routine postoperative care, there has yet to be a comprehensive analysis of the available literature over the past decade to assess the best algorithmic approach to scar care. To this end, a systematic review of best practices in preventative scar management was conducted to elucidate the highest level of evidence available on this subject to date.
Methods: A computerized MEDLINE search was performed for clinical studies addressing scar management. The resulting publications were screened randomized clinical trials that met the authors’ specified inclusion/exclusion criteria.
Results: This systematic review was performed in May of 2016. The initial search for the Medical Subject Headings term “cicatrix” and modifiers “therapy, radiotherapy, surgery, drug therapy, prevention, and control” yielded 13,101 initial articles. Applying the authors’ inclusion/exclusion criteria resulted in 12 relevant articles. All included articles are randomized, controlled, clinical trials.
Conclusions: Optimal scar care requires taking into account factors such as incisional tension, anatomical location, and Fitzpatrick skin type. The authors present a streamlined algorithm for scar prophylaxis based on contemporary level I and II evidence to guide clinical practice.
[Review] Radiotherapy in the setting of breast reconstruction: types, techniques, and timing
[Review] Radiotherapy in the setting of breast reconstruction: types, techniques, and timing
Ho, AY et al
Lancet Oncology December 2017 Vol 18, 12 e742- e753
As the use of breast reconstruction and postmastectomy radiotherapy (PMRT) has increased over the past decade, the typical approach to integrating radiotherapy with breast reconstruction has provoked intense controversy in the management of breast cancer. PMRT can lead to an increased frequency of complications in the reconstructed breast. Conversely, the reconstructed breast can increase the complexity of radiotherapy delivery. How to minimise the frequency of complications without compromising oncological or cosmetic outcomes of the reconstructed breast is an important shared multidisciplinary goal for oncologists and their patients.
Ho, AY et al
Lancet Oncology December 2017 Vol 18, 12 e742- e753
As the use of breast reconstruction and postmastectomy radiotherapy (PMRT) has increased over the past decade, the typical approach to integrating radiotherapy with breast reconstruction has provoked intense controversy in the management of breast cancer. PMRT can lead to an increased frequency of complications in the reconstructed breast. Conversely, the reconstructed breast can increase the complexity of radiotherapy delivery. How to minimise the frequency of complications without compromising oncological or cosmetic outcomes of the reconstructed breast is an important shared multidisciplinary goal for oncologists and their patients.
Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction
Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction
Manahan MA, et al
Plastic and Reconstructive Surgery:December 2017 - Volume 140 - Issue 6 - p 775e–781e
Summary: The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons’ Qualified Clinical Data Registry reporting, and national quality reporting programs.
Manahan MA, et al
Plastic and Reconstructive Surgery:December 2017 - Volume 140 - Issue 6 - p 775e–781e
Summary: The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons’ Qualified Clinical Data Registry reporting, and national quality reporting programs.
The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery
The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery
Losken A et al
Plastic and Reconstructive Surgery: Durgery: January 2018 - Volume 141 - Issue 1 - p 10–19
Background: Autoaugmentation techniques have been applied to oncoplastic reductions to assist with filling larger, more remote defects, and to women with smaller breasts. The purpose of this report is to describe the use of autoaugmentation techniques in oncoplastic reduction and compare the results with those of traditional oncoplastic reduction.
Methods: The authors queried a prospectively maintained database of all women who underwent partial mastectomy and oncoplastic reduction between 1994 and October of 2015. The autoaugmentation techniques were defined as (1) extended primary nipple autoaugmentation pedicle, and (2) primary nipple pedicle and secondary autoaugmentation pedicle. Comparisons were made to a control oncoplastic group. Results: There were a total of 333 patients, 222 patients (67.7 percent) without autoaugmentation and 111 patients (33 percent) with autoaugmentation (51 patients with an extended autoaugmentation pedicle, and 60 patients with a secondary autoaugmentation pedicle). Biopsy weight was smallest in the extended pedicle group (136 g) and largest in the regular oncoplastic group (235 g; p = 0.017). Superomedial was the most common extended pedicle, and lateral was the most common location. Inferolateral was the most common secondary pedicle for lateral and upper outer defects. There were no significant differences in the overall complication rate: 15.5 percent in the regular oncoplastic group, 19.6 percent in the extended pedicle group, and 20 percent in the secondary pedicle group. Conclusions: Autoaugmentation techniques have evolved to manage complex defects not amenable to standard oncoplastic reduction methods. They are often required for lateral defects, especially in smaller breasts. Autoaugmentation can be performed safely without an increased risk of complications, broadening the indications for breast conservation therapy.
Losken A et al
Plastic and Reconstructive Surgery: Durgery: January 2018 - Volume 141 - Issue 1 - p 10–19
Background: Autoaugmentation techniques have been applied to oncoplastic reductions to assist with filling larger, more remote defects, and to women with smaller breasts. The purpose of this report is to describe the use of autoaugmentation techniques in oncoplastic reduction and compare the results with those of traditional oncoplastic reduction.
Methods: The authors queried a prospectively maintained database of all women who underwent partial mastectomy and oncoplastic reduction between 1994 and October of 2015. The autoaugmentation techniques were defined as (1) extended primary nipple autoaugmentation pedicle, and (2) primary nipple pedicle and secondary autoaugmentation pedicle. Comparisons were made to a control oncoplastic group. Results: There were a total of 333 patients, 222 patients (67.7 percent) without autoaugmentation and 111 patients (33 percent) with autoaugmentation (51 patients with an extended autoaugmentation pedicle, and 60 patients with a secondary autoaugmentation pedicle). Biopsy weight was smallest in the extended pedicle group (136 g) and largest in the regular oncoplastic group (235 g; p = 0.017). Superomedial was the most common extended pedicle, and lateral was the most common location. Inferolateral was the most common secondary pedicle for lateral and upper outer defects. There were no significant differences in the overall complication rate: 15.5 percent in the regular oncoplastic group, 19.6 percent in the extended pedicle group, and 20 percent in the secondary pedicle group. Conclusions: Autoaugmentation techniques have evolved to manage complex defects not amenable to standard oncoplastic reduction methods. They are often required for lateral defects, especially in smaller breasts. Autoaugmentation can be performed safely without an increased risk of complications, broadening the indications for breast conservation therapy.
Two-Stage Prosthetic Breast Reconstruction: A Comparison Between Prepectoral and Partial Subpectoral Techniques
Two-Stage Prosthetic Breast Reconstruction: A Comparison Between Prepectoral and Partial Subpectoral Techniques
Nahabedian M Y, CocilovoC
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6S - p 22S–30S
Background: Prosthetic breast reconstruction with prepectoral placement may confer clinical advantages compared with subpectoral placement. The purpose of this study was to assess and compare clinical outcomes following 2-stage reconstruction following prepectoral and partial subpectoral placement of tissue expanders and implants. Methods: A retrospective review of 39 (prepectoral) and 50 (partial subpectoral) patients was completed. Acellular dermal matrix was used in all patients. Mean age was 50.4 and 49.2 years, respectively. Body mass index (BMI) > 30 was noted in 15.4% of prepectoral and 18% of partial subpectoral patients. Radiation therapy was delivered to 38.5% of prepectoral patients and to 22% of partial subpectoral patients. Mean follow-up was 8.7 and 13 months for the prepectoral cohort and partial subpectoral cohorts. Results: The percentage of patients having at least 1 adverse event was 20.5% in the prepectoral and 22% in the partial subpectoral cohorts. The incidence of surgical-site infection and seroma was 8.1% and 4.8%, respectively, for the prepectoral cohort and 4.8% and 2.4%, respectively, for the partial subpectoral cohorts. Device explantation was 6.5% for the prepectoral and 7.2% for the partial subpectoral patients. Explantation did not occur in patients who had radiation or who had a BMI > 30. Four patients (6 breasts—7.2%) required conversion from partial subpectoral to prepectoral because of animation deformity. Conclusions: Prepectoral reconstruction is a viable alternative to partial subpectoral reconstruction. Proper patient selection is an important variable. Prepectoral reconstruction can be safely performed in patients with a BMI < 40 and in patients having postmastectomy radiation therapy.
Nahabedian M Y, CocilovoC
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6S - p 22S–30S
Background: Prosthetic breast reconstruction with prepectoral placement may confer clinical advantages compared with subpectoral placement. The purpose of this study was to assess and compare clinical outcomes following 2-stage reconstruction following prepectoral and partial subpectoral placement of tissue expanders and implants. Methods: A retrospective review of 39 (prepectoral) and 50 (partial subpectoral) patients was completed. Acellular dermal matrix was used in all patients. Mean age was 50.4 and 49.2 years, respectively. Body mass index (BMI) > 30 was noted in 15.4% of prepectoral and 18% of partial subpectoral patients. Radiation therapy was delivered to 38.5% of prepectoral patients and to 22% of partial subpectoral patients. Mean follow-up was 8.7 and 13 months for the prepectoral cohort and partial subpectoral cohorts. Results: The percentage of patients having at least 1 adverse event was 20.5% in the prepectoral and 22% in the partial subpectoral cohorts. The incidence of surgical-site infection and seroma was 8.1% and 4.8%, respectively, for the prepectoral cohort and 4.8% and 2.4%, respectively, for the partial subpectoral cohorts. Device explantation was 6.5% for the prepectoral and 7.2% for the partial subpectoral patients. Explantation did not occur in patients who had radiation or who had a BMI > 30. Four patients (6 breasts—7.2%) required conversion from partial subpectoral to prepectoral because of animation deformity. Conclusions: Prepectoral reconstruction is a viable alternative to partial subpectoral reconstruction. Proper patient selection is an important variable. Prepectoral reconstruction can be safely performed in patients with a BMI < 40 and in patients having postmastectomy radiation therapy.
Important Considerations for Performing Prepectoral Breast Reconstruction
Important Considerations for Performing Prepectoral Breast Reconstruction
Sbitany, H
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6S - p 7S–13S
Summary: Prepectoral breast reconstruction has emerged as an excellent technique for postmastectomy reconstruction, as it allows for full preservation of a patient’s pectoralis major muscle and chest wall function. This reduces pain, eliminates animation deformity, and results in high patient satisfaction. Safely performed prepectoral breast reconstruction requires a careful patient selection process before committing to the procedure, taking into account comorbidities, radiation status, and oncologic criteria such as tumor location and breast cancer stage. Furthermore, a thorough intraoperative assessment of mastectomy skin flaps is critical, with careful and precise confirmation that the skin is viable and well perfused, prior to proceeding with prepectoral breast reconstruction. This can be done both clinically and with perfusion assessment devices. The use of acellular dermal matrix (ADM) has enhanced outcomes and aesthetics of prepectoral reconstruction, by providing implant coverage and soft-tissue support. The ADM also adds the benefit of reducing capsular contracture rates and offers full control over the aesthetic definition of the newly reconstructed breast pocket. Aesthetic enhancement of results requires routine use of oversizing implants in the skin envelope, careful selection of full capacity or cohesive gel implants, and autologous fat grafting. In this way, patients in all clinical scenarios can benefit from the full muscle-sparing technique of prepectoral breast reconstruction, including those undergoing immediate reconstruction, delayed reconstruction, and delayed conversion from a subpectoral to prepectoral plane to correct animation deformity.
Sbitany, H
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6S - p 7S–13S
Summary: Prepectoral breast reconstruction has emerged as an excellent technique for postmastectomy reconstruction, as it allows for full preservation of a patient’s pectoralis major muscle and chest wall function. This reduces pain, eliminates animation deformity, and results in high patient satisfaction. Safely performed prepectoral breast reconstruction requires a careful patient selection process before committing to the procedure, taking into account comorbidities, radiation status, and oncologic criteria such as tumor location and breast cancer stage. Furthermore, a thorough intraoperative assessment of mastectomy skin flaps is critical, with careful and precise confirmation that the skin is viable and well perfused, prior to proceeding with prepectoral breast reconstruction. This can be done both clinically and with perfusion assessment devices. The use of acellular dermal matrix (ADM) has enhanced outcomes and aesthetics of prepectoral reconstruction, by providing implant coverage and soft-tissue support. The ADM also adds the benefit of reducing capsular contracture rates and offers full control over the aesthetic definition of the newly reconstructed breast pocket. Aesthetic enhancement of results requires routine use of oversizing implants in the skin envelope, careful selection of full capacity or cohesive gel implants, and autologous fat grafting. In this way, patients in all clinical scenarios can benefit from the full muscle-sparing technique of prepectoral breast reconstruction, including those undergoing immediate reconstruction, delayed reconstruction, and delayed conversion from a subpectoral to prepectoral plane to correct animation deformity.
Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction
Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction
Weissler, J et al
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6 - p 1110–1118
Background: As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Methods: In an effort to expand on Nahabedian’s 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. Results: The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. Conclusion: With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.
Weissler, J et al
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6 - p 1110–1118
Background: As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Methods: In an effort to expand on Nahabedian’s 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. Results: The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. Conclusion: With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.
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