Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

Novel Approach for Risk-Reducing Mastectomy: First-Stage Implant Placement and Subsequent Second-Stage Mastectomy

 by Lim, Geok Hoon; Baildam, Andrew D.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 607–610

Background: Risk-reducing mastectomy with tissue expander and then implant-based breast reconstruction conventionally involved immediate submuscular placement of tissue expanders during mastectomy and then, after expansion, replacement of expanders for permanent implants in a second-stage operation. Use of acellular dermal matrix can achieve a single-stage operation; however, acellular dermal matrices are costly and may have potential complications. The authors aim to assess the feasibility of placement of implants as a first-stage procedure before risk-reducing mastectomy as a novel technique of reconstruction that avoids the need for serial outpatient expansion and acellular dermal matrix.

Methods: Patients for whom risk-reducing mastectomy was planned were offered first-stage dual-plane placement of fixed volume silicone gel permanent implants by means of inframammary fold incisions. Risk-reducing mastectomy was undertaken several months later as the second operation, leaving the implants in place protected by the muscle and capsule pocket. Nipples were preserved or reconstructed according to the patient’s choice.

Results: Eight patients with 15 operated breasts were recruited. Anatomically shaped implants were used in all patients, and complete coverage of each implant was achieved. Mean implant volume was 433 ml (range, 290 to 545 ml). There were no complications, and good aesthetic outcomes were achieved.

Conclusions: This proof-of-principle study finds that placement of implants before risk-reducing mastectomy is a novel technique for women at high breast cancer risk that could reduce the use of tissue expanders and acellular dermal matrices and their associated problems. Two-stage risk-reducing mastectomy with first-stage implant placement and subsequent risk-reducing mastectomy leaving the implants in place is feasible, with no complications, and can produce a good cosmetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique

Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique

by Sarfati, Benjamin; Struk, Samuel; Leymarie, Nicolas; Honart, Jean-François; Alkhashnam, Heba; Kolb, Frédéric; Rimareix, Françoise  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 624–627

Summary: Robotic nipple-sparing mastectomy could be a significant advancement in the treatment and prophylaxis of selected breast cancers. Motion-scaling, high-resolution, three-dimensional optics; tremor elimination; and instruments with enhanced precision with 7 degrees of freedom have allowed surgeons to overcome the limitations experienced with the endoscopic approach in breast surgery. Advantages of this procedure, in comparison with the open technique, are a shorter and more acceptable scar located in the lateral thoracic region, and greater respect for the vascularization of the mastectomy skin flap, because there is no incision on the breast and no retractors are used. The authors recently received approval from both the French health authorities and the ethics committee to carry out a clinical trial in their institution to assess feasibility, reproducibility, and safety of robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction. The aims of this article are to describe the surgical technique they have developed, and to share, through a video, the clinical experience gained from over 60 procedures performed so far.

Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation

Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation

 by Van Slyke, Aaron C.; Carr, Michael; Carr, Nicholas J.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 281e–289e

Background: Augmentation mammaplasty is the most common aesthetic procedure. Textured implants control implant position and have improved capsular contracture rates; however, the impact of texturing on longevity and clinical findings at explantation is unclear.

Methods: All cases of explantation between January of 2005 and April of 2017 from an aesthetic practice were reviewed retrospectively. Patient demographics, implant characteristics, time to explantation, and clinical presentation and intraoperative findings at explantation were analyzed. Results: Five hundred thirty-nine breast implants were explanted during the study period: 249 saline, 147 smooth gel, 123 Biocell, and 20 other nonaggressively textured breast implants. Average time from placement to explantation was 7.5, 5.6, 4.9, and 4.0 years for saline, other textured, smooth gel, and Biocell implants, respectively (p = 3.25e-08). The percentage of implants removed associated with implant performance failure was 50.3, 57.4, 75.0, and 85.4 percent for smooth gel, saline, other textured, and Biocell implants, respectively (p = 7.25e-09). In addition, 21.1 percent of Biocell implants versus 1.4 percent of all other implants presented with pain (p = 2.71e-15). Forty-five Biocell implants had double capsules; this phenomenon was not observed with any other implant type (p = 5.85e-37). Seven Biocell implants had late seromas, compared to three late seromas with any other implant type (p = 0.0013).

Conclusions: Here, the authors provide evidence that Biocell implants have the shortest time to explantation and the highest proportion of implants associated with implant performance failure. This information should complement the informed consent process when selecting an appropriate implant.

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

by Hart, Alexandra M.; Broecker, Justine S.; Kao, Leslieann; Losken, Albert  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 611–620

Background: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery.

Methods: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded.

Results: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication.

Conclusions: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction

by Hembd, Austin; Teotia, Sumeet S.; Zhu, Hong; Haddock, Nicholas T.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 583–592

Background: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction.

 Methods: The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions.

Results: Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05).

Conclusions: The authors’ results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

[Review] Statistical analysis of patient-reported outcome data in randomised controlled trials of locally advanced and metastatic breast cancer: a systematic review

The Lancet Oncology: Review: Volume 19, issue 9, PE459-PE469, September 01, 2018

Although patient-reported outcomes (PROs), such as health-related quality of life, are important endpoints in randomised controlled trials (RCTs), there is little consensus about the analysis, interpretation, and reporting of these data. We did a systematic review to assess the variability, quality, and standards of PRO data analyses in advanced breast cancer RCTs. We searched PubMed for English language articles published in peer-reviewed journals between Jan 1, 2001, and Oct 30, 2017. Eligible articles were those that reported PRO results from RCTs of adult patients with advanced breast cancer receiving anti-cancer treatments with reported sample sizes of at least 50 patients—66 RCTs met the selection criteria.

[News] New triple-negative breast cancer risk genes identified

[News] New triple-negative breast cancer risk genes identified

by Elizabeth Gourd

The Lancet Oncology : News: Volume 19, issue 9 PE445, September 01, 2018

Multigene hereditary cancer panel testing could be used to identify women with an elevated risk of triple-negative breast cancer as a result of deleterious mutations in five genes, according to a recent study.

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

by Vera Lidwina Negenborn, Danny Aschwin Young-Afat, Rieky Elise Gustina Dikmans, Jan Maerten Smit, Henri Adolf Hubert Winters, Johan Peter William Don Griot, Johannes Wilhelmus Rembertus Twisk, Pieter Quinten Ruhé, Marcus Antonius Maria Mureau, Oren Lapid, Esther Moerman, Adriaan Anne William Martinus van Turnhout, Mathias Joseph Petrus Franciscus Ritt, Mark-Bram Bouman, Margriet Gezina Mullender

The Lancet Oncology: Volume 19, issue 9, P1205-1214, September 01, 2018

Taken together with our previously published findings, one-stage IBBR with ADM does not yield superior results in terms of patient-reported QOL compared with two-stage IBBR. Risks for adverse outcomes were significantly higher in the one-stage ADM group. Use of ADM for one-stage IBBM should be considered on a case-by-case basis.

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

By O’Connell, Rachel L.; Di Micco, Rosa; Khabra, Komel; Kirby, Anna M.; Harris, Paul A.; James, Stuart E.; Power, Kieran; Ramsey, Kelvin W. D.; Rusby, Jennifer E.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 594–605

Background: The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group.

Methods: Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images. Results: One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy.

Conclusions: Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or “delayed-immediate” reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

by Turin, Sergey Y.; Li, Daniel D.; Vaca, Elbert E.; Fine, Neil  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 264e–270e

Background: Mastectomy flap necrosis remains a challenging complication in immediate tissue expander breast reconstruction. Nitroglycerin ointment has been shown to reduce the incidence of mastectomy flap necrosis in a randomized controlled study, using 45 g per breast and treating one side only in bilateral cases. This study was conducted to determine the efficacy of 15 g of nitroglycerin ointment per breast, therefore permitting application to both breasts in cases of bilateral mastectomy. Methods: A retrospective cohort study of patients undergoing immediate tissue expander breast reconstruction performed by a single reconstructive surgeon was conducted. The intervention cohort consisted of all patients between June 10, 2015, and June 9, 2016 (94 patients, 158 breasts), where 15 g of nitroglycerin ointment was routinely applied per breast. The control cohort consisted of all patients from June 10, 2014, to June 9, 2015 (107 patients, 170 breasts), where nitroglycerin was not applied. All complications were tracked, including minor wound healing problems. Results: There was an overall 22 percent decreased incidence of mastectomy flap necrosis in the nitroglycerin ointment cohort (47.5 percent versus 60.6 percent; p = 0.002), with a 44 percent reduction in full-thickness mastectomy flap necrosis that trended toward statistical significance (9.5 percent versus 16.5 percent; p = 0.06). On multivariate analysis, nitroglycerin application was independently associated with a decrease in mastectomy flap necrosis or need for mastectomy flap débridement. There was no significant difference in the incidence of postoperative hypotension (3.8 percent versus 2.9 percent) or headache among cohorts. Conclusion: Topical nitroglycerin ointment application to mastectomy skin flaps at 15 g per breast is a cost-effective means of decreasing the incidence of mastectomy flap necrosis in unilateral and bilateral immediate tissue expander breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens

Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens

by Arlene Chan, Astrid Bauwens, Sally Pontre, Sally Jackson, Frances McGlone, Tracie Ernenwein, Jun Chih, Christopher Reid  

The Breast: October 2018 Volume 41, Pages 127–132

Hair loss as a result of chemotherapy for early breast cancer (EBC) is a frequent and distressing side effect. Minimising hair loss may improve mood and body image. Our aim was to determine scalp cooling (SC) efficacy in EBC patients receiving contemporary chemotherapy regimen, to inform future patients choice to use SC or not.