Tuesday, 14 August 2018

Evidence-Based Interventions: Consultation Document [PDF] (see page 43-47)

Source:  NHS England - 10 July 2018 - Publisher: NHS England
NHS England is seeking views on the proposed policy for reducing the delivery of clinically ineffective interventions. Consultation ends on 28 September 2018.

Complementary therapies, relaxation and wellbeing (BCC55) [PDF]

Source:  Breast Cancer Care - 26 June 2018 (via NICE)

This booklet is about relaxation and wellbeing during and after breast cancer treatment. It looks at complementary therapies such as acupuncture, Reiki and massage. It also describes some popular relaxation techniques, including meditation and mindfulness, and has information on yoga, Tai Chi and Chi Gung. We discuss why people might use these complementary therapies and relaxation techniques after a diagnosis of breast cancer, and what you may need to think about before trying them. We also explain what herbal medicines and homeopathy are.

*Please let me know whether resources like this are of any use to you. If so, I'll just do a NICE search in relation to breast surgery each month to accompany the research articles. 

Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men

Plastic and Reconstructive Surgery   by Frey, Jordan D.; Yu, Jessie Z.; Poudrier, Grace; Motosko, Catherine C.; Saia, Whitney V.; Wilson, Stelios C.; Hazen, Alexes  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 331–336

Background: A primary goal in chest wall reconstruction (“top surgery”) for trans men is achieving a symmetric, aesthetically pleasing position of the reconstructed male nipple-areola complex. Methods: The senior author’s (A.H.) technique for component nipple-areola complex creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March of 2015 to October of 2016. Results: The average patient age was 30.64 years, and the average body mass index was 28.54 kg/m2. Eighty-two percent of the sample received preoperative testosterone therapy, and average operative time was 2 hours 59 minutes. Average overall mastectomy specimen weight was 627.80 g, average length of hospital stay was 0.96 days, and average follow-up duration was 19.02 months. Complications occurred in five patients (10 percent), including seroma (4 percent), cellulitis (2 percent), hematoma (2 percent), and suture granuloma (2 percent). Only five patients (10 percent) underwent postoperative revision to adjust nipple-areola complex size, projection, or symmetry. Twenty-eight patients (56 percent) underwent secondary revisions, including scar revisions (56 percent), liposuction (12 percent), and fat grafting (2 percent). Conclusion: The use of a modified nipple flap and free areola graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male nipple-areola complex in a safe and effective manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction

by Cohen, Oriana; Lam, Gretl; Choi, Mihye; Ceradini, Daniel; Karp, Nolan  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 299–305

Background: Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, the authors determine how postoperative complications impact chemotherapy timing, and identify factors associated with greater risk for delays. Methods: Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of postoperative complications and time to chemotherapy. Results: A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86 percent) reconstructions did not experience postoperative complications, and 34 (13.9 percent) did. Patients who experienced postoperative complications had an older mean age (53.6 years versus 48.1 years; p = 0.002) and higher rates of diabetes (23.5 percent versus 3.8 percent; p < 0.001). The complication group had delays in initiation of chemotherapy (56 versus 45 days; p = 0.017). Patients who initiated chemotherapy more than 48.5 days after reconstruction were of older mean age (55.9 years versus 50.7 years; p = 0.074) and had increased rates of diabetes (36.8 percent versus 6.7 percent; p = 0.053) and immediate autologous reconstruction (31.6 percent versus 0 percent; p = 0.027). A predictive model determined that patients with at least one of these three risk factors have a 74 percent chance of experiencing prolonged times to chemotherapy initiation. Conclusions: Risk factors for delayed chemotherapy in the context of postoperative complications are age older than 51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

[Perspectives] Breast cancer in a Renaissance Book of the Dead

The Lancet Oncology by Emma Nicholls  


Walking around galleries of great Renaissance art, many visitors have found themselves staring in puzzlement at female nudes who seem to have oddly shaped breasts. In recent years, a number of medical specialists, working in partnership with art historians, have argued that we should be less quick to dismiss these apparent malformations as the result of artistic ineptitude. Instead, they argue that to the trained eye, these bulges, depressions, and retractions unmistakably signal the willingness of Renaissance artists to depict women with breast pathologies.

[News] Mammography deficiencies: the result of poor positioning

The Lancet Oncology by Elizabeth Gourd  

NEWS| VOLUME 19, ISSUE 8, PE385, AUGUST 01, 2018

Poor patient positioning is the leading cause of clinical image deficiencies and accreditation failures in mammography, according to a recent investigation.

Comparing Therapeutic versus Prophylactic Nipple-Sparing Mastectomy: Does Indication Inform Oncologic and Reconstructive Outcomes?

by Frey, Jordan D.; Salibian, Ara A.; Karp, Nolan S.; Choi, Mihye  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 306–315

Background: Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. Methods: Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. Results: A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). Conclusions: Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases

by Opsomer, Dries; Stillaert, Filip; Blondeel, Phillip; Van Landuyt, Koenraad  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 1e–8e

Background: The lumbar artery perforator flap is an alternative flap in breast reconstruction for those patients who are not eligible for a deep inferior epigastric artery perforator (DIEAP) flap. Shaping of this flap is easier compared with other flaps because of the quality of the lumbar fat and the gluteal extension. Methods: Between October of 2010 and June of 2017, a total of 100 lumbar artery perforator free flap breast reconstructions were performed in 72 patients. Patient demographics, indications, flap specifics, and complications were reviewed retrospectively. Results: Twenty-eight bilateral and 44 unilateral breast reconstructions with a lumbar artery perforator flap were performed. Mean patient age was 48 years, and the average body mass index was 23.11 kg/m2. The authors report 43 preventive mastectomies for elevated cancer risk with subsequent immediate reconstruction, 34 secondary reconstructions, and 14 tertiary reconstructions. Mean operative time was 7 hours 4 minutes, including the mastectomy in primary cases. Mean flap weight was 499 g (range, 77 to 1216 g) and mean follow-up time was 30 months. The revision rate was 22 percent and nine flaps were lost. Conclusions: The lumbar artery perforator flap is a valuable alternative to the DIEAP flap in breast reconstructive surgery. It is an excellent flap for BRCA-positive patients who are typically young and have limited excess tissue at the conventional donor sites. Despite higher revision rates compared with the DIEAP flap, the lumbar flap is superior in mimicking the shape and feel of native breast tissue. Scarring at the donor site remains a sore point but can be easily treated and used to an advantage to contour the flanks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Implications of Barbed Sutures on Scar Aesthetics: A Systematic Review

Authors: Motosko, Catherine C., B.S.; Zakhem, George A., B.S.; Saadeh, Pierre B., M.D.; Hazen, Alexes, M.D.
Journal: Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 337–343

Background: Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast operations, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regard to scarring.
Methods: A systematic review of the PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July of 2017 using the search terms “barbed suture” combined with “scar” or “wound.” Studies were included if they were prospective, evaluator-blind, randomized, controlled trials; closed the dermal layer of incisions using barbed sutures; and included an evaluator-blind aesthetic assessment of scarring.
Results: Six prospective, randomized, controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the six controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and one study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in four of the five studies that timed incision closure. Similar complication rates were observed in all evaluated studies.
Conclusion: Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.