Comparing the Lumbar and SGAP Flaps to the DIEP Flap Using the BREAST-Q

 

Comparing the Lumbar and SGAP Flaps to the DIEP Flap Using the BREAST-Q

 

by Opsomer, Dries; Vyncke, Tom; Ryx, Michelle; Stillaert, Filip; Van Landuyt, Koenraad; Blondeel, Phillip 

 

Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 276e-282e

 

Background:

The deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. When the abdomen is not available, alternative donor sites can be found at the buttock, the lumbar region, or the thighs. These flaps are referred to as second-choice flaps. This study compares the superior gluteal artery perforator (SGAP) flap and the lumbar artery perforator (LAP) flap to the DIEP flap using patient-reported outcomes.

Methods:

A retrospective study was performed reviewing the records of 417 women who underwent a free flap breast reconstruction with either a DIEP, an LAP, or an SGAP flap, between 2006 and 2018. Patients were asked to fill out the BREAST-Q questionnaire, and patient-reported outcomes were analyzed and correlated to the demographic information.

Results:

The response rate was 54.5 percent, with 50 LAP, 153 DIEP, and 25 SGAP flap patients participating. When questioned about their satisfaction with breasts and satisfaction with outcome, all three procedures were rated similarly high. When comparing the physical well-being of the donor site and appearance of the donor site, LAP flap patients reported significantly lower scores than DIEP and SGAP flap patients.

Conclusions:

Patients who undergo LAP or SGAP flap breast reconstruction seem similarly satisfied with the appearance and outcome of their free flap breast reconstruction compared with DIEP flap patients. The donor-site morbidity and its impact on the patient’s well-being in SGAP and LAP flap patients have been underestimated. Despite more donor-site discomfort, the LAP and SGAP flaps are feasible alternatives whenever the DIEP flap is not possible.

Comparison of Telfa Rolling and a Closed Washing System for Autologous Fat Processing Techniques in Postmastectomy Breast Reconstruction

 

Comparison of Telfa Rolling and a Closed Washing System for Autologous Fat Processing Techniques in Postmastectomy Breast Reconstruction

 

Valmadrid, Al C.; Kaoutzanis, Christodoulos; Wormer, Blair A.; Farinas, Angel F.; Wang, Li; Al Kassis, Salam; Perdikis, Galen; Braun, Stephane A.; Higdon, Kent K

 

Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 486-497

 

Background:

The purpose of this study was to compare the commonly used fat grafting techniques—Telfa rolling and a closed washing system—in breast reconstruction patients.

Methods:

Consecutive patients undergoing fat grafting were retrospectively reviewed and grouped by technique. Patients with less than 180 days of follow-up were excluded. Demographics, operative details, and complications were compared using univariate analysis with significance set at p < 0.05.

Results:

Between January of 2013 and September of 2017, 186 women underwent a total of 319 fat grafting procedures. There was no difference in demographics, number of procedures performed, volume of fat grafted, and number of days after reconstruction that fat grafting was performed between groups (p > 0.05). Telfa rolling patients had longer operative times for second fat grafting procedures (implant exchange often completed prior) [100.0 minutes (range, 60.0 to 150.0 minutes) versus 79.0 minutes (range, 64.0 to 94.0 minutes); p = 0.03]. Telfa rolling breasts had more palpable masses requiring imaging (26.0 percent versus 14.4 percent; p = 0.01) and an increased incidence of fat necrosis (20.6 percent versus 8.0 percent; p < 0.01). The closed washing system was found to be an independent predictor of decreased rates of imaging-confirmed fat necrosis (OR, 0.29; p = 0.048). There was no difference in fat necrosis excision or cancer recurrence between the groups.

Conclusion:

The closed washing system was independently associated with decreased rates of imaging-confirmed fat necrosis compared to Telfa rolling without an increase in other complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Final results of the UK Age trial on breast cancer screening age

 

Final results of the UK Age trial on breast cancer screening age

by Anthony B Miller

 

The Lancet Oncology: VOLUME 21, ISSUE 9, P1125-1126, SEPTEMBER 01, 2020

In The Lancet Oncology, the findings from a 23-year follow-up of the UK Age trial are presented by Stephen Duffy and colleagues.1 No difference in mortality from breast cancer was found between the group that began yearly mammography screening at age 39–41 years until they entered the National Health Service (NHS) Breast Screening Programme at age 50–52 years, and a group that did not begin mammography screening until they entered the NHS Breast Screening Programme (126 deaths vs 255 deaths occurring after more than 10 years of follow-up; relative rate 0·98 [95% CI 0·79–1·22]; p=0·86).

Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial

 Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial

by Stephen W Duffy, Daniel Vulkan, Howard Cuckle, Dharmishta Parmar, Shama Sheikh, Robert A Smith, Andrew Evans, Oleg Blyuss, Louise Johns, Ian O Ellis, Jonathan Myles, Peter D Sasieni, Sue M Moss

 

The Lancet Oncology:  VOLUME 21, ISSUE 9, P1165-1172, SEPTEMBER 01, 2020

 

Background

The appropriate age range for breast cancer screening remains a matter of debate. We aimed to estimate the effect of mammographic screening at ages 40–48 years on breast cancer mortality.

Methods

We did a randomised, controlled trial involving 23 breast screening units across Great Britain. We randomly assigned women aged 39–41 years, using individual randomisation, stratified by general practice, in a 1:2 ratio, to yearly mammographic screening from the year of inclusion in the trial up to and including the calendar year that they reached age 48 years (intervention group), or to standard care of no screening until the invitation to their first National Health Service Breast Screening Programme (NHSBSP) screen at approximately age 50 years (control group). Women in the intervention group were recruited by postal invitation. Women in the control group were unaware of the study. The primary endpoint was mortality from breast cancers (with breast cancer coded as the underlying cause of death) diagnosed during the intervention period, before the participant's first NHSBSP screen. To study the timing of the mortality effect, we analysed the results in different follow-up periods. Women were included in the primary comparison regardless of compliance with randomisation status (intention-to-treat analysis). This Article reports on long-term follow-up analysis. The trial is registered with the ISRCTN registry, ISRCTN24647151.

Findings

160 921 women were recruited between Oct 14, 1990, and Sept 24, 1997. 53 883 women (33·5%) were randomly assigned to the intervention group and 106 953 (66·5%) to the control group. Between randomisation and Feb 28, 2017, women were followed up for a median of 22·8 years (IQR 21·8–24·0). We observed a significant reduction in breast cancer mortality at 10 years of follow-up, with 83 breast cancer deaths in the intervention group versus 219 in the control group (relative rate [RR] 0·75 [95% CI 0·58–0·97]; p=0·029). No significant reduction was observed thereafter, with 126 deaths versus 255 deaths occurring after more than 10 years of follow-up (RR 0·98 [0·79–1·22]; p=0·86).

Interpretation

Yearly mammography before age 50 years, commencing at age 40 or 41 years, was associated with a relative reduction in breast cancer mortality, which was attenuated after 10 years, although the absolute reduction remained constant. Reducing the lower age limit for screening from 50 to 40 years could potentially reduce breast cancer mortality.

Funding

National Institute for Health Research Health Technology Assessment programme.

 See responses to this: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30528-3/fulltext?rss=yes#section-7c530872-6235-4433-899c-b3f276970189

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30528-3/fulltext?rss=yes#section-7c530872-6235-4433-899c-b3f276970189 (as of 24.11.2020) 

Olaparib and durvalumab in patients with germline BRCA-mutated metastatic breast cancer (MEDIOLA): an open-label, multicentre, phase 1/2, basket study

 Olaparib and durvalumab in patients with germline BRCA-mutated metastatic breast cancer (MEDIOLA): an open-label, multicentre, phase 1/2, basket study

 

by Susan M Domchek, Sophie Postel-Vinay, Seock-Ah Im, Yeon Hee Park, Jean-Pierre Delord, Antoine Italiano, Jerome Alexandre, Benoit You, Sara Bastian, Matthew G Krebs, Ding Wang, Saiama N Waqar, Mark Lanasa, Joon Rhee, Haiyan Gao, Vidalba Rocher-Ros, Emma V Jones, Sakshi Gulati, Anna Coenen-Stass, Iwanka Kozarewa, Zhongwu Lai, Helen K Angell, Laura Opincar, Pia Herbolsheimer, Bella Kaufman

 

The Lancet Oncology: VOLUME 21, ISSUE 9, P1155-1164, SEPTEMBER 01, 2020

 

Background

Poly (ADP-ribose) polymerase inhibitors combined with immunotherapy have shown antitumour activity in preclinical studies. We aimed to assess the safety and activity of olaparib in combination with the PD-L1-inhibitor, durvalumab, in patients with germline BRCA1-mutated or BRCA2-mutated metastatic breast cancer.

Methods

The MEDIOLA trial is a multicentre, open-label, phase 1/2, basket trial of durvalumab and olaparib in solid tumours. Patients were enrolled into four initial cohorts: germline BRCA-mutated, metastatic breast cancer; germline BRCA-mutated, metastatic ovarian cancer; metastatic gastric cancer; and relapsed small-cell lung cancer. Here, we report on the cohort of patients with breast cancer. Patients who were aged 18 years or older (or aged 19 years or older in South Korea) with germline BRCA1-mutated or BRCA2-mutated or both and histologically confirmed, progressive, HER2-negative, metastatic breast cancer were enrolled from 14 health centres in the UK, the USA, Israel, France, Switzerland, and South Korea. Patients should not have received more than two previous lines of chemotherapy for metastatic breast cancer. Patients received 300 mg olaparib in tablet form orally twice daily for 4 weeks and thereafter a combination of olaparib 300 mg twice daily and durvalumab 1·5 g via intravenous infusion every 4 weeks until disease progression. Primary endpoints were safety and tolerability, and 12-week disease control rate. Safety was analysed in patients who received at least one dose of study treatment, and activity analyses were done in the full-analysis set (patients who received at least one dose of study treatment and were not excluded from the study). Recruitment has completed and the study is ongoing. This trial is registered with ClinicalTrials.gov, NCT02734004.

Findings

Between June 14, 2016, and May 2, 2017, 34 patients were enrolled and received both study drugs and were included in the safety analysis. 11 (32%) patients experienced grade 3 or worse adverse events, of which the most common were anaemia (four [12%]), neutropenia (three [9%]), and pancreatitis (two [6%]). Three (9%) patients discontinued due to adverse events and four (12%) patients experienced a total of six serious adverse events. There were no treatment-related deaths. 24 (80%; 90% CI 64·3–90·9) of 30 patients eligible for activity analysis had disease control at 12 weeks.

Interpretation

Combination of olaparib and durvalumab showed promising antitumour activity and safety similar to that previously observed in olaparib and durvalumab monotherapy studies. Further research in a randomised setting is needed to determine predictors of therapeutic benefit and whether addition of durvalumab improves long-term clinical outcomes compared with olaparib monotherapy.

Funding

AstraZeneca.

Stability of Long-Term Outcomes in Implant-Based Breast Reconstruction: An Evaluation of 12-Year Surgeon- and Patient-Reported Outcomes in 3489 Nonirradiated and Irradiated Implants

 

Stability of Long-Term Outcomes in Implant-Based Breast Reconstruction: An Evaluation of 12-Year Surgeon- and Patient-Reported Outcomes in 3489 Nonirradiated and Irradiated Implants

 

by Seth, Akhil K.; Cordeiro, Peter G. 

 

Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 474-484

 

Background:

Outcomes following prosthetic breast reconstruction have been well studied. However, the majority of studies are limited by short-term follow-up and a lack of aesthetic and patient-reported outcomes. This study objectively examines long-term surgeon- and patient-reported outcomes following two-stage prosthetic breast reconstruction.

Methods:

Consecutive patients undergoing two-stage prosthetic breast reconstruction from 1994 to 2016 performed by the senior author (P.G.C.), with at least 1-year follow-up after implant exchange, were reviewed retrospectively. Long-term surgeon-reported outcomes, including aesthetic and capsular contracture scores, and patient-reported outcomes using the BREAST-Q, were recorded at each outpatient visit and analyzed over the 12-year follow-up period.

Results:

Retrospective review revealed 2284 patients, or 3489 breasts, that fit the inclusion criteria. Aesthetic scores and capsular contracture rates remained stable over the entire follow-up period. Subset analysis demonstrated that bilateral and nonirradiated reconstructions consistently had the highest aesthetic scores, whereas unilateral irradiated breasts had the lowest. Irradiated breasts consistently had high rates of capsular contracture, although the extent of contracture improved over time in all patients. Patient-reported BREAST-Q scores showed either stability or improvement over time in all patients. Irradiated and nonirradiated patients demonstrated comparable long-term satisfaction with outcomes despite significant differences in satisfaction with their breasts.

Conclusions:

The authors’ study, the largest of its kind, demonstrates that prosthetic breast reconstruction outcomes do not deteriorate over time. This stability is apparent in both long-term surgeon- and patient-reported outcomes data measured in the same patients. These results contradict the surgical dogma surrounding prosthetic breast reconstruction and therefore should be given significant consideration when counseling patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Venous Thromboembolism following Microsurgical Breast Reconstruction: A Longitudinal Analysis of 12,778 Patients

 

Venous Thromboembolism following Microsurgical Breast Reconstruction: A Longitudinal Analysis of 12,778 Patients

 

by Rochlin, Danielle H.; Sheckter, Clifford C.; Pannucci, Christopher; Momeni, Arash 

 

Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 465-473

 

Background:

Venous thromboembolism is a dreaded complication following microsurgical breast reconstruction. Although the high-risk nature of the procedure is well known, a thorough analysis of modifiable risk factors has not been performed. The purpose of this study was to analyze the association of such factors with the postoperative occurrence of venous thromboembolism longitudinally.

Methods:

Using the Truven MarketScan Database, a retrospective cohort study of women who underwent microsurgical breast reconstruction from 2007 to 2015 and who developed postoperative venous thromboembolism within 90 days of reconstruction was performed. Predictor variables included age, timing of reconstruction, body mass index, history of radiation therapy, history of venous thromboembolism, Elixhauser Comorbidity Index, and length of stay. Univariate analyses were performed, in addition to logistic and zero-inflated Poisson regressions, to evaluate predictors of venous thromboembolism and changes in venous thromboembolism over the study period, respectively.

Results:

Twelve thousand seven hundred seventy-eight women were identified, of which 167 (1.3 percent) developed venous thromboembolism. The majority of venous thromboembolisms (67.1 percent) occurred following discharge, with no significant change from 2007 to 2015. Significant predictors of venous thromboembolism included Elixhauser score (p < 0.01), history of venous thromboembolism (p < 0.03), and length of stay (p < 0.001). Compared to patients who developed a venous thromboembolism during the inpatient stay, patients who developed a postdischarge venous thromboembolism had a lower mean Elixhauser score (p < 0.001).

Conclusions:

Postoperative venous thromboembolism continues to be an inadequately addressed problem, as evidenced by a stable incidence over the study period. Identification of modifiable risk factors, such as length of stay, provides potential avenues for intervention. As the majority of venous thromboembolisms occur following discharge, future studies are warranted to investigate the role for an intervention in this period. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes

 

Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes

 by Colohan, Shannon M.; Massenburg, Benjamin B.; Gougoutas, Alexander J. 

 Plastic and Reconstructive Surgery: September 2020 - Volume 146 - Issue 3 - p 339e-350e

 

Learning Objectives:

 After studying this article, the participant should be able to:

1. Understand the relevant anatomy involved in breast reduction.

2. Understand the different breast reduction techniques and their indications.

3. Appreciate the outcomes of these techniques as they pertain to clinical outcomes.

 

Summary:

 This continuing medical education article is designed to refresh one’s knowledge on breast reduction while placing emphasis on clinical outcomes. It reviews the relevant anatomy, techniques, and published literature on outcomes, including those that are patient-reported. Photographic representations of most techniques are shown, in addition to supplemental digital video content, to demonstrate each technique. This is designed to be an overview, and the reader should appreciate that no one technique is “right,” and the technique used should be selected with patient factors and desired outcomes in mind.

Toward International Harmonization of Breast Implant Registries: International Collaboration of Breast Registry Activities Global Common Data Set

 

Toward International Harmonization of Breast Implant Registries: International Collaboration of Breast Registry Activities Global Common Data Set

 

by Spronk, Pauline E. R.; Begum, Husna; Vishwanath, Swarna; Crosbie, Andy; Earnest, Arul; Elder, Elisabeth; Lumenta, David B.; Marinac-Dabic, Danica; Moore, Colin C. M.; Mureau, Marc A. M.; Perks, Graeme; Pusic, Andrea L.; Stark, Birgit; von Fritschen, Uwe; Klein, Howard; Cooter, Rodney D.; Rakhorst, Hinne A.; Hopper, Ingrid

 

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 255-267

 

Background:

The Poly Implant Prothèse incident and breast implant-associated anaplastic large cell lymphoma have pointed to the need for uniform registries for breast implants as key features to monitoring the outcomes of breast implant surgeries internationally. The purpose of this study was to identify and harmonize common data elements collected by breast implant registries across the International Collaboration of Breast Registry Activities (ICOBRA) global consortium.

 Methods:

The authors convened an international group of surgeons, consumers, nurses, registry experts, and regulators to review the data points. A modified Delphi approach was applied, to rate the importance of each point on a six-point Likert scale.

Results:

Data points from six national breast implant registries were divided into categories: clinical, implant-related, patient-reported findings; operation details and implanting technique details; patient characteristics; unique device identifiers; unique patient identifiers; and clinical demographics. A total of 52 data points collected by over 33 percent of national registries were identified. After five rounds, 34 data points formed the final set with agreed definitions. The group recognized the critical importance of additional elements that are currently not uniformly collected (e.g., patient-reported outcomes and long-term data) and set out the process for the dynamic global set updates driven by evidence gaps.

Conclusions:

The authors defined internationally agreed on common data elements and definitions used in breast implant registries. This collaboration will allow data sets to be combined, enabling an effective global early warning system of implant-related problems and further work on data sets.

The Efficacy of Breast Implant Irrigant Solutions: A Comparative Analysis Using an In Vitro Model

The Efficacy of Breast Implant Irrigant Solutions: A Comparative Analysis Using an In Vitro Model

by Ngaage, Ledibabari M.; Elegbede, Adekunle; Brao, Kristen; Chopra, Karan; Gowda, Arvind U.; Nam, Arthur J.; Ernst, Robert K.; Shirtliff, Mark E.; Harro, Janette; Rasko, Yvonne M.

 

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 301-308

 

Background:

Infections are challenging complications of implant-based breast reconstruction and augmentation. They pose a clinical challenge, with significant economic implications. One proposed solution is implant irrigation at the time of placement. There is no consensus on the optimal irrigant solution.

Methods:

The authors tested the relative efficacy of 10% povidone-iodine, Clorpactin, Prontosan, triple-antibiotic solution, or normal saline (negative control) against two strains each of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis. Sterile, smooth silicone implant disks were immersed in irrigant solution, then incubated in suspensions of methicillin-resistant S. aureus or S. epidermidis overnight. The disks were rinsed and sonicated to displace adherent bacteria from the implant surface, and the displaced bacteria were quantified. Normalized values were calculated to characterize the relative efficacy of each irrigant.

Results:

Povidone-iodine resulted in reductions of the bacterial load by a factor of 104 to 105 for all strains. Prontosan-treated smooth breast implant disks had a 10-fold reduction in bacterial counts for all but one methicillin-resistant S. aureus strain. In comparison to Prontosan, triple-antibiotic solution demonstrated a trend of greater reduction in methicillin-resistant S. aureus bacterial load and weaker activity against S. epidermidis strains. Clorpactin reduced the recovered colony-forming units for only a single strain of S. epidermidis. Povidone-iodine demonstrated the greatest efficacy against all four strains. However, Clorpactin, triple-antibiotic solution, and Prontosan demonstrated similar efficacies.

Conclusions:

Povidone-iodine was the most efficacious of the irrigants at reducing methicillin-resistant S. aureus and S. epidermidis contamination. Given the recent lifting of the U.S. Food and Drug Administration moratorium, larger clinical studies of povidone-iodine as a breast implant irrigant solution are warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction

 

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction

by Black, Cara K.; Zolper, Elizabeth G.; Economides, James M.; Abadeer, Andrew; Fan, Kenneth L.; Song, David H.

Plastic and Reconstructive Surgery:  August 2020 - Volume 146 - Issue 2 - p 137e-146e

Background:

Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making.

Methods:

 A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures.

Results:

Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05).

Conclusions:

Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.