Tuesday, 13 August 2019

Benchmarking the Outcomes of Single-Stage Augmentation Mastopexy against Primary Breast Augmentation: A Single Surgeon’s Experience of 905 Consecutive Cases

by Montemurro, Paolo; Cheema, Mubashir; Hedén, Per; Behr, Björn; Wallner, Christoph 

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 326-334

Background: Augmentation mastopexy may be a one- or two-stage procedure. Because of the opposing force vectors in augmentation and in mastopexy, some surgeons advocate a two-stage procedure. The literature appears divided on which operation has a more favorable complication profile. The purpose of this review was to benchmark the outcomes of single-stage augmentation mastopexy against those of a commonly performed aesthetic breast operation (primary breast augmentation).

Methods: The authors reviewed electronic patient records of all consecutive female patients who underwent single-stage augmentation mastopexy and primary breast augmentation performed by the first author at our clinic between April of 2009 and May of 2017 with at least a 6-month follow-up. Data from single-stage augmentation mastopexy were benchmarked against the outcomes of primary breast augmentations performed by the same surgeon, for the same period, and at the same clinic.

Results: One hundred four single-stage augmentation mastopexies and 801 primary breast augmentations were performed during this period, with mean follow-up of 15.4 months and 14.0 months, respectively. Augmentation mastopexy patients were significantly more likely to be older, have a higher body mass index, have more children, and were significantly less likely to use oral contraceptives. There was no statistically significant difference in overall complication rate between the two groups.

Conclusions: The authors’ experience suggests that single-stage augmentation mastopexy has outcomes comparable to those of primary breast augmentation. Smokers were more likely to undergo reoperation because of postoperative complication (seroma), but the rate of implant exchange was not different. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Fat Grafting and the Palpable Breast Mass in Implant-Based Breast Reconstruction: Incidence and Implications

by Knackstedt, Rebecca W.; Gatherwright, James; Ataya, Dana; Duraes, Eliana F. R.; Schwarz, Graham S. 

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 265-275

Background: Fat grafting is a powerful and increasingly used technique in breast reconstruction. However, fat necrosis can lead to palpable postoperative changes that can induce anxiety and lead to unplanned diagnostic studies. The authors’ aim in this study was to evaluate the incidence, type, and timing of these unanticipated studies; the specialty of the ordering provider; and the factors that trigger the ordering process.

Methods: A retrospective chart review was conducted for patients from 2006 to 2015 who underwent fat grafting as part of implant-based breast cancer reconstruction and had at least 1-year follow-up after fat grafting.

Results: From 2006 to 2015, 166 patients underwent fat grafting as part of implant-based breast reconstruction. Forty-four women (26.5 percent) underwent at least one imaging procedure. Thirteen women (7.8 percent) underwent 17 biopsies. For a palpable mass, the initial imaging test most commonly ordered was ultrasound, followed by mammography/ultrasound. The percentage of patients with a diagnosis of fat necrosis on mammography, ultrasound, and biopsy was 4.2, 12.7, and 5.4 percent, respectively. Seven patients (4.2 percent) had distant metastases. Tissue diagnosis of local recurrence was never identified. Mean follow-up was 2.4 years.

Conclusions: Fat-grafting sequelae may lead to early unplanned invasive and noninvasive procedures initiated by a variety of providers. In this study, fat grafting had no impact on local recurrence rate. As use of fat grafting grows, communication among breast cancer care providers and enhanced patient and caregiver education will be increasingly important in optimizing the multidisciplinary evaluation and monitoring of palpable breast lesions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement

by Wormer, Blair A.; Valmadrid, Al C.; Ganesh Kumar, Nishant; Al Kassis, Salam; Rankin, Timothy M.; Kaoutzanis, Christodoulos; Higdon, Kent K.

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 276-286

Background: The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates.

Methods: Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p < 0.05.

Results: In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p > 0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p < 0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p < 0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393).

Conclusion: This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction

by Kim, John Y. S.; Qiu, Cecil S.; Chiu, Wen-Kuan; Feld, Lauren N.; Mioton, Lauren M.; Kearney, Aaron; Fracol, Megan

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 291-301

Background: Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis.

Methods: Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy.

Results: One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Interrater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84).

Conclusions: This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction

by Beugels, Jop; Cornelissen, Anouk J. M.; van Kuijk, Sander M. J.; Lataster, Arno; Heuts, Esther M.; Piatkowski, Andrzej; Spiegel, Aldona J.; van der Hulst, René R. W. J.; Tuinder, Stefania M. H

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 178e-188e

Background: The sensory recovery of the breast remains an undervalued aspect of autologous breast reconstruction. The aim of this study was to evaluate the effect of nerve coaptation on the sensory recovery of the breast following DIEP flap breast reconstruction and to assess the associations of length of follow-up and timing of the reconstruction.

Methods: A prospective comparative study was conducted of all patients who underwent either innervated or noninnervated DIEP flap breast reconstruction and returned for follow-up between September of 2015 and July of 2017. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Semmes-Weinstein monofilaments were used for sensory testing of the native skin and flap skin.

Results: A total of 48 innervated DIEP flaps in 36 patients and 61 noninnervated DIEP flaps in 45 patients were tested at different follow-up time points. Nerve coaptation was significantly associated with lower monofilament values in all areas of the reconstructed breast (adjusted difference, −1.2; p < 0.001), which indicated that sensory recovery of the breast was significantly better in innervated compared with noninnervated DIEP flaps. For every month of follow-up, the mean monofilament value decreased by 0.083 in innervated flaps (p < 0.001) and 0.012 in noninnervated flaps (p < 0.001). Nerve coaptation significantly improved sensation in both immediate and delayed reconstructions. 

Conclusions: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction is associated with a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. The length of follow-up was significantly associated with the sensory recovery.

Trastuzumab duocarmazine in locally advanced and metastatic solid tumours and HER2-expressing breast cancer: a phase 1 dose-escalation and dose-expansion study

by Udai Banerji, Carla M L van Herpen, Cristina Saura, Fiona Thistlethwaite, Simon Lord, Victor Moreno, Iain R Macpherson, Valentina Boni, Christian Rolfo, Elisabeth G E de Vries, Sylvie Rottey, Jill Geenen, Ferry Eskens, Marta Gil-Martin, Ellen C Mommers, Norbert P Koper, Philippe Aftimos

The Lancet Oncology: Articles| volume  20, issue  8, p1124-1135, August  01, 2019

Trastuzumab duocarmazine shows notable clinical activity in heavily pretreated patients with HER2-expressing metastatic cancer, including HER2-positive trastuzumab emtansine-resistant and HER2-low breast cancer, with a manageable safety profile. Further investigation of trastuzumab duocarmazine for HER2-positive breast cancer is ongoing and trials for HER2-low breast cancer and other HER2-expressing cancers are in preparation.

MRI versus mammography for breast cancer screening in women with familial risk (FaMRIsc): a multicentre, randomised, controlled trial

by Sepideh Saadatmand, H Amarens Geuzinge, Emiel J T Rutgers, Ritse M Mann, Diderick B W de Roy van Zuidewijn, Harmien M Zonderland, Rob A E M Tollenaar, Marc B I Lobbes, Margreet G E M Ausems, Martijne van 't Riet, Maartje J Hooning, Ingeborg Mares-Engelberts, Ernest J T Luiten, Eveline A M Heijnsdijk, Cees Verhoef, Nico Karssemeijer, Jan C Oosterwijk, Inge-Marie Obdeijn, Harry J de Koning, Madeleine M A Tilanus-Linthorst, FaMRIsc study group

The Lancet Oncology: Articles| volume 20 issue 8, p1136-1147, August 01, 2019

MRI screening detected cancers at an earlier stage than mammography. The lower number of late-stage cancers identified in incident rounds might reduce the use of adjuvant chemotherapy and decrease breast cancer-related mortality. However, the advantages of the MRI screening approach might be at the cost of more false-positive results, especially at high breast density.

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction

by Siotos, Charalampos; Naska, Androniki; Bello, Ricardo J.; Uzosike, Akachimere; Orfanos, Philippos; Euhus, David M.; Manahan, Michele A.; Cooney, Carisa M.; Lagiou, Pagona; Rosson, Gedge D.

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 169e-177e

Background: Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. Methods: The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence.

Results: The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). 

Conclusion: This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

By Roy, Mélissa; Sebastiampillai, Stephanie; Zhong, Toni; Hofer, Stefan O. P.; O’Neill, Anne C. 

Plastic and Reconstructive Surgery: July 2019 - Volume 144 - Issue 1 - p 1e-8e

Background: Microvascular breast reconstruction is a complex procedure that can be associated with high complication rates. Although a number of individual predictors of perioperative complications have been identified, few studies have explored interaction between risk factors. Understanding the synergistic effects of multiple risk factors is central to accurate and personalized preoperative risk prediction.

Methods: The authors conducted a retrospective cohort study of patients who underwent microvascular breast reconstruction at their institution between 2009 and 2017. All intraoperative and postoperative complications were recorded. A multivariable logistic regression exploratory model identified independent predictors of complications. Interactions between individual variables were then assessed using the relative excess risk index (RERI) and the synergy index (SI).

Results: Nine hundred twelve patients were included in the study and 26.1 percent experienced at least one perioperative complication. Obesity (OR, 1.54; p = 0.009), immediate reconstruction (OR, 1.49; p = 0.028), and comorbidities (OR, 1.43; p = 0.033) were identified as independent predictors of complications. Obesity and comorbidities had significant synergistic interactions with immediate reconstruction (RERI, 0.86; SI, 2.35; p = 0.0002; and RERI, 0.54; SI, 1.78; p = 0.001), bilateral reconstruction (RERI, 0.12; SI, 1.15; p = 0.002; and RERI, 0.59; SI, 3.16; p = 0.005), and previous radiotherapy (RERI, 0.62; SI, 4.43; p = 0.01; and RERI, 0.11; SI, 1.23; p = 0.040). Patients undergoing immediate breast reconstruction who were both obese and smokers had a 12-fold increase in complication rates (OR, 12.68; 95 percent CI, 1.36 to 118.46; p = 0.026) with a very strong synergistic interaction between variables (RERI, 10.55; SI, 10.33).

Conclusion: Patient- and treatment-related variables interact in a synergistic manner to increase the risk of complications following microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.