Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy

Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy

by Hanson, Summer E.; Kapur, Sahil K.; Garvey, Patrick B.; Hernandez, Mike; Clemens, Mark W.; Hwang, Rosa F.; Dryden, Mark J.; Butler, Charles E.

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 215-225

Background:

Autologous fat grafting is a useful adjunct following breast reconstruction. The impact of autologous fat grafting on oncologic safety and surveillance remains questionable, particularly following breast conservation therapy.

Methods:

The authors performed a retrospective review of patients who underwent delayed fat grafting following breast conservation therapy between 2006 and 2016. A control group of conservatively managed patients without grafting was matched for cancer stage, age, body mass index, and follow-up. Outcomes included locoregional recurrence and oncologic surveillance.

Results:

Seventy-two patients were identified per cohort. There were no differences in median age (50 years versus 51 years; p = 0.87), body mass index (28.2 kg/m2 versus 27.2 kg/m2; p = 0.38), or length of follow-up (61.9 months versus 66.8 months; p = 0.144) between controls and grafted patients, respectively. Overall, four patients in each cohort experienced recurrence (5.6 percent; p = 1.00) with similar cumulative incidence estimates observed (log-rank test, p = 0.534). There were no significant differences in palpable mass (9.7 percent versus 19.4 percent; p = 0.1), fat necrosis (34.7 percent versus 33.3 percent; p = 0.86), calcifications (37.5 percent versus 34.7 percent; p = 0.73), or indication for breast biopsy (15.3 percent versus 22.2 percent; p = 0.23) between breast conservation and breast conservation therapy plus autologous fat grafting cohorts, respectively.

Conclusions:

Overall, the authors found no difference in recurrence rates after breast conservation with or without delayed fat grafting. Furthermore, there were no differences in the rates of fat necrosis, palpable mass, and abnormal radiographic findings. This study represents the longest follow-up to date in in a large matched study of autologous fat grafting with breast conservation therapy demonstrating oncologic safety and no interference with follow-up surveillance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Should we worry about residual disease after mastectomy?

Should we worry about residual disease after mastectomy?

by Orit Kaidar-Person, Thorsten Kühn, Philip Poortmans 

The Lancet Oncology: volume 21, issue 8, p1001-1013. August 01, 2020

Breast cancer is the most frequently diagnosed cancer in women, accounting for 30% of new cancer cases, and leads to the highest proportion (15%) of cancer deaths.1 Surgical resection is the cornerstone of treatment with curative intent for patients with non-metastatic breast cancer, within comprehensive treatment from an integrated multidisciplinary team. The aim of resection is to remove all neoplastic tissue in the breast (both invasive cancer and ductal carcinoma in situ [DCIS]), to reduce the risk of further disease spread, including local and distant recurrence.

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Knowledge gaps in oncoplastic breast surgery (Review)

 Knowledge gaps in oncoplastic breast surgery (Review)

by Walter P Weber, Monica Morrow, Jana de Boniface, Andrea Pusic, Giacomo Montagna, Elisabeth A Kappos, Mathilde Ritter, Martin Haug, Christian Kurzeder, Ramon Saccilotto, Alexandra Schulz, John Benson, Florian Fitzal, Zoltan Matrai, Jane Shaw, Marie-Jeanne Vrancken Peeters, Shelley Potter, Joerg Heil, Oncoplastic Breast Consortium

The Lancet Oncology: volume 21, issue 8 (375-385), August 01, 2020 

The aims of the Oncoplastic Breast Consortium initiative were to identify important knowledge gaps in the field of oncoplastic breast-conserving surgery and nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction, and to recommend appropriate research strategies to address these gaps. A total of 212 surgeons and 26 patient advocates from 55 countries prioritised the 15 most important knowledge gaps from a list of 38 in two electronic Delphi rounds. An interdisciplinary panel of the Oncoplastic Breast Consortium consisting of 63 stakeholders from 20 countries obtained consensus during an in-person meeting to select seven of these 15 knowledge gaps as research priorities.

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Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery

Link to article: Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery

by Djohan, Risal; Scomacao, Isis; Knackstedt, Rebecca; Cakmakoglu, Cagri; Grobmyer, Stephen R. 

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 250-254

Summary:

The concept of sensate autologous breast reconstruction is not novel, and prior literature has focused mainly on sensate abdominally based breast reconstruction. The goal of this article is to present the authors’ results with a novel technique performing sensate implant-based reconstruction. A database was prospectively maintained for patients who underwent implant-based sensate breast reconstruction. The anterior branch of the lateral fourth intercostal is identified and preserved during the mastectomy by the breast surgeon. A processed nerve allograft is used as an interpositional graft connecting the donor nerve to the targeted nipple-areola complex. The sensory recovery process was objectively monitored using a pressure-specified sensory device. Thirteen patients underwent the proposed technique. Eight patients with 15 breasts were monitored for sensory recovery. For sensory measurement, the nipple had a mean threshold of 67.33 ± 34.48 g/nm2. The upper inner (29 ± 26.75 g/nm2) and upper outer (46.82 ± 32.72 g/nm2) nipple-areola complex quadrants demonstrated better scores during the moving test compared with the static test. Mean time between the test and surgery was 4.18 ± 2.3 months, and mean time between the second test and surgery was 10.59 ± 3.57 months. Threshold improvements were documented after the second test for all nipple-areola complex areas evaluated. This is the first study to report on early results obtained after performing sensate implant-based breast reconstruction. More studies are required to determine the long-term outcomes and impact on quality of life and to assess whether patient or breast characteristics impact the success of this procedure.

Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

Link to article: Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

by Weissler, Jason M.; Banuelos, Joseph; Jacobson, Steven R.; Manrique, Oscar J.; Nguyen, Minh-Doan T.; Harless, Christin A.; Tran, Nho V.; Martinez-Jorge, Jorys

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 238-245

Background:

Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction.

Methods:

 A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher’s exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.

Results:

A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma.

Conclusions:

 Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Health-Related Quality of Life after Four Common Surgical Treatment Options for Breast Cancer and the Effect of Complications: A Retrospective Patient-Reported Survey among 1871 Patients

Link to article: Long-Term Health-Related Quality of Life after Four Common Surgical Treatment Options for Breast Cancer and the Effect of Complications: A Retrospective Patient-Reported Survey among 1871 Patients

by Kouwenberg, Casimir A. E.; de Ligt, Kelly M.; Kranenburg, Leonieke W.; Rakhorst, Hinne; de Leeuw, Daniëlle; Siesling, Sabine; Busschbach, Jan J.; Mureau, Marc A. M.

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1-13

Background:

Differences in quality-of-life outcomes after different surgical breast cancer treatment options, including breast reconstruction, are relevant for counseling individual patients in clinical decision-making, and for (societal) evaluations such as cost-effectiveness analyses. However, current literature shows contradictory results, because of use of different patient-reported outcome measures and study designs with limited patient numbers. The authors set out to improve this evidence using patient-reported outcome measures in a large, cross-sectional study for different surgical breast cancer treatment options.

Methods:

Quality of life was assessed through the EQ-5D-5L, European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and BR23, and the BREAST-Q. Patients with different treatments were compared after propensity-weighted adjustment of pretreatment differences. The EQ-5D was used to value the effect of surgical complications.

Results:

A total of 1871 breast cancer patients participated (breast-conserving surgery, n = 615; mastectomy, n = 507; autologous reconstruction, n = 330; and implant-based reconstruction, n = 419). Mastectomy patients reported the lowest EQ-5D score (mastectomy, 0.805, breast-conserving surgery, 0.844; autologous reconstruction, 0.849; and implant-based reconstruction, 0.850) and functioning scores of the C30 questionnaire. On the BREAST-Q, autologous reconstruction patients had higher mean Satisfaction with Outcome, Satisfaction with Breasts, and Sexual Well-being scores than implant-based reconstruction patients. Complications in autologous reconstruction patients resulted in a substantially lower quality of life than in implant-based reconstruction patients.

Conclusions:

This study shows the added value of breast conservation and reconstruction compared with mastectomy; however, differences among breast-conserving surgery, implant-based reconstruction, and autologous breast reconstruction were subtle. Complications resulted in poorer health-related quality of life.

Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

Link to article: Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

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

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1e-10e

Background:

This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction.

Methods:

 A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure.

Results:

Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits.

Conclusion:

Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Attachments of the Breast to the Chest Wall: A Dissection Study

Link to article: The Attachments of the Breast to the Chest Wall: A Dissection Study

by Gaskin, Kathryn M.; Peoples, Gregory E.; McGhee, Deirdre E. 

Plastic and Reconstructive Surgery :  July 2020 - Volume 146 - Issue 1 - p 11-22e

Background: 

The anatomical descriptions of the attachments of the female breast to the chest wall vary in their structure, location, and terminology within the published literature.

Methods: 

A dissection study of the attachments of the breast to the chest wall was conducted on 18 female embalmed breasts in the coronal (n = 15) and sagittal planes (n = 3).

Results: 

Perimeter, posterior wall, and horizontal septum attachments were observed. The perimeter along its entire length was attached to the chest wall. Regional and anatomical variation was observed in this structure and location. Sharp dissection was required to remove it from the chest wall, in contrast to the blunt dissection required to remove the posterior wall and horizontal septum attachments.

Conclusions: 

The breast attaches to the chest wall along its entire perimeter, posterior wall, and horizontal septum, with the perimeter functioning as the primary anchor of the breast to the chest wall. The structure of the perimeter attachment is both periosteal and fascial and requires sharp dissection to remove it from the chest wall. The fascial structures of the posterior wall and horizontal septum require blunt dissection only. The structure of the perimeter has regional variation, and its location on the chest wall has anatomical variation. Detailed anatomical descriptions and illustrations are supported by photographic evidence of cadaver dissections in two planes. Clinical and anatomical terminology are linked, with clinical implications for medical anatomy education, breast modeling, and breast surgery.