Acceptance of contralateral reduction mammoplasty after oncoplastic breast conserving surgery: A semi-structured qualitative interview study

Acceptance of contralateral reduction mammoplasty after oncoplastic breast conserving surgery: A semi-structured qualitative interview study

by Hansje P. Smeele, Eline M.L. Van der Does de Willebois, Yassir Eltahir, Geertruida H. De Bock, Vera C. Van Aalst, Liesbeth Jansen

The Breast: June 2019, Volume 45, Pages 97-103

Oncoplastic breast conserving surgery (BCS) frequently induces asymmetry. Contralateral reduction mammoplasty (CRM) is therefore part of the oncoplastic approach. Our patients frequently declined CRM when offered as a second-stage procedure after the completion of adjuvant treatments. This qualitative interview study was conducted to explore the factors involved in patient decision-making about CRM.

Locoregional surgical treatment improves the prognosis in primary metastatic breast cancer patients with a single distant metastasis except for brain metastasis

Locoregional surgical treatment improves the prognosis in primary metastatic breast cancer patients with a single distant metastasis except for brain metastasis

by Xiaolin Li, Run Huang, Lisi Ma, Sixuan Liu, Xiangyun Zong  

The Breast: June 2019, Volume 45, Pages 104-112

We aimed to validate the clinical significance of locoregional surgery in improving the prognosis of primary metastatic breast cancer (pMBC).

Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice

Trends in axillary lymph node dissection for early-stage breast cancer in Europe: Impact of evidence on practice

by Carlos A. Garcia-Etienne, Robert E. Mansel, Mariano Tomatis, Joerg Heil, Laura Biganzoli, Alberta Ferrari, Lorenza Marotti, Adele Sgarella, Antonio Ponti, EUSOMA Working Group  

The Breast: June 2019, Volume 45, Pages 89-96

Data from recently published trials have provided practice-changing recommendations for the surgical approach to the axilla in breast cancer. Patients with T1-2 lesions, treated with breast conservation, who have not received neoadjuvant chemotherapy and have 1–2 positive sentinel nodes (Z0011-criteria) may avoid axillary lymph node dissection (ALND). We aim to describe the dissemination of this practice in Europe over an extended period of time.

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC)

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC)

 by M. Taffurelli, A. Pellegrini, I. Meattini, L. Orzalesi, C. Tinterri, M. Roncella, D. Terribile, F. Caruso, G. Tazzioli, G. Pollini, D. Friedman, C. Mariotti, E. Cianchetti, C. Cabula, R. Thomas, C. Cedolini, F. Rovera, M. Grassi, G. Lucani, A. Cappella, M. Bortul, G. Stacul, F. Scarabeo, E. Procaccini, V. Galimberti  

The Breast: June 2019, Volume 45, Pages 56-60

Breast angiosarcoma is a malignant mesenchymal neoplasm, which accounts for approximately 2% of all soft tissue sarcomas. Secondary breast angiosarcoma (SBA) may be related to chronic lymphedema after a mastectomy with lymph node dissection (Stewart Treves syndrome) and previous radiotherapy for complications from breast radiation treatment. It is a very rare condition; therefore, diagnosis and management are still a challenge.

How to Improve Projection in Nipple Reconstruction: A Modified Method Using Acellular Dermal Matrix Disk and Fragments

How to Improve Projection in Nipple Reconstruction: A Modified Method Using Acellular Dermal Matrix Disk and Fragments

by Lee, Hun Joo; Ock, Jae Jin  

Plastic and Reconstructive Surgery: April 2019 - Volume 143 - Issue 4 - p 698e-706e

Background: Nipple reconstruction is an essential, final stage in breast reconstruction. However, postoperative reduction in nipple projection often results in low patient satisfaction. The authors studied the causes of the projection decline and developed a new method using acellular dermal matrix. This research studies the effectiveness of the new method.

Methods: The nipple flap was elevated using a modified C-V flap, and acellular dermal matrix disk was fixed onto the floor. A column was made, into which acellular dermal matrix fragments were put in to retain the projection. The footprint diameter and projection at 1 year were compared with those of the control group, in which acellular dermal matrix was not used. The authors studied the correlation between diameter and projection and whether reconstruction method caused any impact.

Results: At 1-year follow-up, the nipple diameter and projection in the acellular dermal matrix group were measured to be 102.90 percent and 64.19 percent, respectively, of the baseline. Compared with the control group, the diameter was significantly smaller (p = 0.00) and the projection was higher (p = 0.00). A significant correlation was identified between nipple diameters and projections, at 1-year follow-up, across the total 90 reconstructed nipples (p = 0.00). Different reconstruction methods did not show significant differences in terms of nipple diameter and projection, but the projections at 1 year were highest in the latissimus dorsi flap plus implant group, followed by the expander group and the transverse rectus abdominis musculocutaneous flap group.

Conclusion: Nipple reconstruction using acellular dermal matrix disk and fragments prevents downward shifting of the nipple tissue and broadening of the footprint diameter and thus is favorable for long-term maintenance of nipple projection.

Complication Profiles by Mastectomy Indication in Tissue Expander Breast Reconstruction

Complication Profiles by Mastectomy Indication in Tissue Expander Breast Reconstruction

 by Chouairi, Fouad; Gabrick, Kyle S.; Avraham, Tomer; Markov, Nickolay P.; Alperovich, Michael  

Plastic and Reconstructive Surgery: April 2019 - Volume 143 - Issue 4 - p 682e-687e

Background: Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exist regarding reconstruction complication rates examined by mastectomy indication.

Methods: Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011 to 2017 were included in the study. Perioperative complications were compared. Chi-square analysis, t tests, and Fisher’s exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis.

Results: Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p = 0.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p = 0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups.

Conclusions: Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than those undergoing prophylactic mastectomies. Although the underlying cause still needs to be determined, differences in technique may be related to mastectomy flap necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Safety Profiles of Fat Processing Techniques in Autologous Fat Transfer for Breast Reconstruction

Safety Profiles of Fat Processing Techniques in Autologous Fat Transfer for Breast Reconstruction

by Ruan, Qing Zhao; Rinkinen, Jacob R.; Doval, Andres F.; Scott, Benjamin B.; Tobias, Adam M.; Lin, Samuel J.; Lee, Bernard T.

Plastic and Reconstructive Surgery: April 2019 - Volume 143 - Issue 4 - p 985-991

Background: Autologous fat transfer is common in breast reconstruction because of its versatility for use in contour deformities. The authors examined three different fat grafting processing techniques for complications and safety profile using their institutional database.

Methods: Retrospective review was performed of patients from a single institution who had undergone autologous fat transfer following breast reconstruction from 2012 to 2016. Individuals were separated into three cohorts according to fat harvest technique: (1) centrifugation, (2) Telfa gauze, or (3) Revolve. Complications between the groups were assessed. Results: A total of 267 cases of autologous fat transfer were identified (centrifugation, n = 168; Telfa, n = 44; and Revolve, n = 55). Grafting by means of centrifugation was associated with the greatest incidence of oil cysts (12.5 percent; p = 0.034), postoperative adverse events observed in the clinic (13.7 percent; p = 0.002), and total complications (25.6 percent; p = 0.001). The use of Telfa resulted in the lowest rates of oil cyst formation (0 percent; p = 0.002) and total complications (2.3 percent; p = 0.001). Grafting by means of centrifugation was also associated with the highest frequency of repeated injections among the three techniques after initial grafting (19.6 percent; p = 0.029). In contrast, Revolve demonstrated a repeated injection rate of just 5.45 percent, significantly lower when independently compared with centrifugation (p = 0.011). Multivariate analysis demonstrated that higher total graft volume (p = 0.002) and the use of centrifugation (p = 0.002) were significant risk factors for adverse events seen in the clinic postoperatively.

Conclusions: Significant differences in postoperative outcomes exist between varying fat transfer techniques. Autologous fat transfer by means of centrifugation harbored the highest rates of complication, whereas Telfa and Revolve exhibited similar safety profiles. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

by DellaCroce, Frank J.; DellaCroce, Hannah C.; Blum, Craig A.; Sullivan, Scott K.; Trahan, Christopher G.; Wise, M. Whitten; Brates, Irena G.

Plastic and Reconstructive Surgery:  April 2019 - Volume 143 - Issue 4 - p 992-1008

Background: Anatomical variations in perforator arrangement may impair the surgeon’s ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap.

Methods: A single surgeon’s experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange (“APEX”) arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion. 

Results: The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.

Conclusions: This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.