Wednesday, 23 January 2019

Tissue Expander Complications Do Not Preclude a Second Successful Implant-Based Breast Reconstruction

by Poppler, Louis H.; Mundschenk, Minh-Bao; Linkugel, Andrew; Zubovic, Ema; Dolen, Utku C.; Myckatyn, Terence M.  

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 24–34

Background: Implant-based breast reconstruction is the most common method of breast reconstruction in the United States, but the outcomes of subsequent implant-based reconstruction after a tissue expander complication are rarely studied. The purpose of this study was to determine the long-term incidence of implant loss in patents with a previous tissue expander complication. Methods: This is a retrospective review of the long-term outcomes of all patients with tissue expander complications at a large academic medical center from 2003 to 2013. Patients with subsequent tissue expander or implant complications were compared to those with no further complications to assess risk factors for additional complications or reconstructive failure.
Results: One hundred sixty-two women were included in this study. The mean follow-up period was 8.3 ± 3.1 years. Forty-eight women (30 percent) went on to undergo a second tissue expander or implant placement. They did not differ from women who went on to autologous reconstruction or no further reconstruction. Of these, 34 women (71 percent) had no further complications and 38 women (79 percent) had a successful implant-based reconstruction at final follow-up. There were no patient or surgical factors significantly associated with a second complication or implant loss. 
Conclusions: Following tissue expander complications, it is reasonable to offer women a second attempt at tissue expansion and implant placement. This study demonstrates that long-term success rates are high, and there are no definitive patient or surgical factors that preclude a second attempt at implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Evaluation of Prepectoral Implant Placement and Complete Coverage with TiLoop Bra Mesh for Breast Reconstruction: A Prospective Study on Long-Term and Patient-Reported BREAST-Q Outcomes

by Casella, Donato; Di Taranto, Giuseppe; Marcasciano, Marco; Sordi, Silvia; Kothari, Ashutosh; Kovacs, Tibor; Lo Torto, Federico; Cigna, Emanuele; Calabrese, Claudio; Ribuffo, Diego

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 1e–9e

Background: Breast reconstruction is rapidly evolving, because of the changing face of cancer surgery and the growing acceptance of acellular dermal matrices and synthetic meshes. Although some early reports showed encouraging results after prepectoral breast reconstruction, there is a paucity of data on long-term outcomes.
Methods: Between January of 2012 and March of 2015, 179 patients undergoing mastectomy were enrolled at the authors’ institution. Patients underwent mastectomy and immediate prepectoral breast reconstruction with the definitive implant entirely wrapped in a titanium-coated polypropylene mesh (TiLoop). The BREAST-Q questionnaire was administered before surgery and after 2 years. Capsular contracture was evaluated using the Baker scale. Oncologic, surgical, and aesthetic outcomes and changes in BREAST-Q score were analyzed over time.
Results: Average follow-up was 38.5 months. A total of 250 mastectomies were performed. The locoregional recurrence rate was 2.1 percent. Complications requiring reoperation were recorded in six patients (2.4 percent) and implant removal was necessary in three cases (1.2 percent), followed by reconstruction with submuscular expanders. Grade IV capsular contracture was detected in five breasts (2 percent), whereas 212 breasts were evaluated as grade I (84.8 percent), 28 breasts as grade II (11.2 percent), and five breasts as grade III (2 percent). Patients reported significant high rates in the BREAST-Q overall Satisfaction with Outcome (73.8), overall Satisfaction with Breasts (72.5), Psychosocial Well-being (77.7), and Sexual Well-being (57.9), scoring a significant increase in these domains from the preoperative period to the postoperative period (p < 0.05).
Conclusion: The authors report encouraging results of a prepectoral direct-to-implant reconstruction technique using a synthetic mesh, supporting the evaluation of the muscle-sparing subcutaneous approach as a valid alternative to traditional submuscular reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Use of Tumescent Technique in Mastectomy and Related Complications: A Meta-Analysis

by Siotos, Charalampos; Aston, Jeffrey W.; Euhus, David M.; Seal, Stella M.; Manahan, Michele A.; Rosson, Gedge D

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 39–48

Background: Postoperative skin necrosis in surgical patients is costly to hospitals and health care providers. Tumescent dissection technique is commonly used in mastectomy and immediate breast reconstruction, as it helps reduce blood loss; however, it may increase the risk of mastectomy skin flap necrosis. In this context, the authors have conducted a systematic review of the literature to perform a meta-analysis of the relationship between tumescent technique in mastectomy with or without breast reconstruction and complication rates.
Methods: The authors screened the PubMed (1966 to 2016), Scopus (2004 to 2016), Embase (1966 to 2016), and Web of Science (1964 to 2016) databases for relevant articles through March 30, 2017. The authors included studies on the use of tumescent technique in the context of mastectomy with or without immediate breast reconstruction. The primary outcome the authors evaluated was the rate of skin flap necrosis; the secondary outcomes were the rates of breast hematomas and infections. Because of the heterogeneity of the studies, the authors performed a meta-analysis using the random effects model.
Results: After screening, the authors evaluated five studies including 3982 mastectomies. Mastectomies performed under the preoperative application of tumescent solution had statistically higher rates of skin flap necrosis overall (p = 0.03) and major (p < 0.01) and minor skin necrosis (p = 0.03). However, the rates of hematoma and infection were not correlated with the use of tumescent technique.
Conclusions: The authors’ systematic review of the literature provides a better understanding of the consequences of the application of tumescent technique in mastectomy. The authors’ findings suggest that tumescent technique may increase the risk of skin necrosis in mastectomy with or without breast reconstruction.

Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits

by Sbitany, Hani; Gomez-Sanchez, Clara; Piper, Merisa; Lentz, Rachel  

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 10–20

Background: Prepectoral breast reconstruction following mastectomy has become a more widely performed technique in recent years because of its numerous benefits for women. These include full pectoralis muscle preservation, reduced loss of strength, reduced pain, and elimination of animation deformity. As with any breast reconstruction technique, widespread adoption is dependent on a low morbidity profile in the setting of postmastectomy radiation therapy, as this adjuvant therapy is routine in breast cancer treatment. The authors assess the clinical outcomes of patients undergoing postmastectomy radiation therapy following prepectoral breast reconstruction, and compare these to outcomes of patients undergoing postmastectomy radiation therapy with submuscular reconstruction.
Methods: A single surgeon’s experience with immediate prepectoral breast reconstruction, followed by postmastectomy radiation therapy, from 2015 to 2017 was reviewed. Patient demographics and incidence of complications during the tissue expander stage were assessed. In addition, the morbidity profile of these patients was compared to that of patients undergoing submuscular/dual-plane reconstruction and postmastectomy radiation therapy over the same period. Results: Over 3 years, 175 breasts underwent immediate prepectoral reconstruction, and 236 breasts underwent immediate submuscular/dual-plane reconstruction. Overall rates of adjuvant radiation therapy (postmastectomy radiation therapy) were similar between prepectoral [26 breasts (14.9 percent)] and submuscular [31 breasts (13.1 percent)] (p = 0.6180) reconstruction. There were no significant differences in complication rates between the two reconstructive cohorts, in the setting of postmastectomy radiation therapy, including rates of explantation (15.4 percent versus 19.3 percent; p = 0.695).
Conclusions: Prepectoral breast reconstruction is a safe and effective option in the setting of postmastectomy radiation therapy. The morbidity profile is similar to that encountered with submuscular reconstruction in this setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A New Method for Partial Breast Reconstruction: 3-Year New Zealand Experience

by Harman, John; Govender, Stan; Simpson, John; Benjamin, Benji  

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 49–52

Summary: In New Zealand, oncoplastic surgery is common, but partial breast reconstruction presents challenges for radiation therapy targeting. Tissue rearrangement creates ambiguity when targeting the tumor bed, with resultant overestimation of treatment volumes. Thus, adoption of advanced methods of radiation therapy have been hindered. This pilot study describes use of a novel three-dimensional implant that provides a scaffolding for tissue ingrowth during partial breast reconstruction and delineates the tumor bed more precisely to assist radiation planning and mammographic surveillance. After informed consent, 15 women were implanted with the three-dimensional bioabsorbable implant. The device was sutured to the tumor bed during lumpectomy, and tissue flaps were mobilized and attached to the implant. Visualization of the marker and radiation treatment volumes were recorded and compared. The implant provided volume replacement and helped to maintain breast contour. Cosmetic outcomes were excellent; no device- or radiation-related complications occurred. One patient had a postoperative hematoma that resolved after percutaneous drainage; there were no postoperative infections. Three-year follow-up shows no tumor recurrences and no untoward effects. When compared to conventional radiation targeting, use of the implant showed that a greater than 50 percent reduction in treatment volume was possible in some cases. Three-year mammograms show no significant artifact, normal tissue ingrowth, and minimal fibrosis. This study describes a method of oncoplastic breast reconstruction using an implantable device that marks the site of tumor excision and provides for volume replacement with tissue ingrowth. Patients tolerated it well, and radiation therapy planning, positioning, and treatment were facilitated.

T-DM1 for residual, invasive, HER2-positive breast cancer

by Talha Khan Burki  

The Lancet Oncology: Volume 20, Issue 1, PE13, January 01, 2019

A new study has concluded that adjuvant trastuzumab emtansine (T-DM1) reduces the risk of recurrence or death in patients with HER2-positive breast cancer who have residual disease after neoadjuvant therapy and surgery. In the phase 3, open-label trial, women with HER2-positive, early-stage breast cancer had received neoadjuvant therapy consisting of at least six cycles of chemotherapy, including a taxane, and trastuzumab for at least 9 weeks. Patients were randomly assigned to receive 14 cycles of either T-DM1 or trastuzumab (n=743 per group).

Use of letrozole after aromatase inhibitor-based therapy in postmenopausal breast cancer (NRG Oncology/NSABP B-42): a randomised, double-blind, placebo-controlled, phase 3 trial

by Eleftherios P Mamounas, Hanna Bandos, Barry C Lembersky, Jong-Hyeon Jeong, Charles E Geyer, Priya Rastogi, Louis Fehrenbacher, Mark L Graham, Stephen K Chia, Adam M Brufsky, Janice M Walshe, Gamini S Soori, Shaker R Dakhil, Thomas E Seay, James L Wade, Edward C McCarron, Soonmyung Paik, Sandra M Swain, D Lawrence Wickerham, Norman Wolmark

The Lancet Oncology: Volume 20, issue 1, P88-99, January 01, 2019

After 5 years of aromatase inhibitor-based therapy, 5 years of letrozole therapy did not significantly prolong disease-free survival compared with placebo. Careful assessment of potential risks and benefits is required before recommending extended letrozole therapy to patients with early-stage breast cancer.

Total Muscle Coverage versus AlloDerm Human Dermal Matrix for Implant-Based Breast Reconstruction

by Ivey, J. Simon; Abdollahi, Hamid; Herrera, Fernando A.; Chang, Eric I

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 1–6

Background: Prosthetic breast reconstruction is the most common method for treatment of patients undergoing mastectomy. Acellular dermal matrix has become more popular in implant-based breast reconstruction. Methods: The authors conducted a retrospective review of all patients undergoing prosthetic breast reconstruction between August of 2002 and December of 2013. Patients were analyzed in terms of demographics, fill volumes, number of expansions, costs, and complications. Results: A total of 284 patients underwent mastectomy surgery with 481 implant-based breast reconstructions. Four hundred eight tissue expanders had total muscle coverage, whereas 73 had AlloDerm. The rate of overall complications and major complications was significantly higher in the AlloDerm group: 20.5 percent versus 8.8 percent (p = 0.005), and 13.7 percent versus 5.1 percent (p = 0.0001), respectively. The mean initial fill volume was significantly lower in the total muscle coverage group compared to the acellular dermal matrix group (54 ± 47 versus 167 ± 139; p = 0.00003), resulting in a higher number of expansions (8.1 versus 5.8; p = 0.000051) and longer time to full expansion (60.2 days versus 43.3 days; p = 0.0002). This did not translate into a faster time to expander exchange (162.4 days versus 162.3 days; p = 0.13). Use of AlloDerm added a mean cost of $2217 for each breast.
Conclusions: Implant-based breast reconstruction has evolved with the advent of acellular dermal matrices. Although the use of acellular dermal matrix allows increased initial fill volumes and fewer total expansions, there is an increased risk of complications and increased costs, especially in patients undergoing bilateral reconstruction. Total muscle coverage remains an excellent option for providing quality breast reconstruction without increased complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.