Locoregional Cancer Recurrence after Breast Reconstruction: Detection, Management, and Secondary Reconstructive Strategies

Locoregional Cancer Recurrence after Breast Reconstruction: Detection, Management, and Secondary Reconstructive Strategies

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1322–1330

Background: Locoregional recurrence of the previously reconstructed breast poses a diagnostic and operative challenge. This study examines detection, management, and reconstructive strategies of locoregional recurrence following postmastectomy breast reconstruction.

Methods: A retrospective review of records was performed on patients treated within the health system for breast cancer from January of 2000 to July of 2014. Of these patients, descriptive factors and operative details were collected for those that developed locoregional recurrence. Subsequent reconstructive operations were also examined. Using a multidisciplinary team, a surveillance/management algorithm was generated.

Results: A total of 41 patients with locoregional recurrence were identified (mean time to recurrence, 4.6 years). Two- and 5-year survival following locoregional recurrence was 88 percent and 39 percent, respectively. Locoregional recurrence was found to occur in the following tissue planes: subcutaneous (27 percent), subcutaneous/pectoralis (24 percent), chest wall (37 percent), and axillary (12 percent). The most frequent method of detection was patient concern leading to examination. Older age at the time of locoregional recurrence (p = 0.028), increased time to recurrence/detection (p = 0.024), and chemotherapy before locoregional recurrence (p = 0.014) were associated with the need for a secondary salvage flap. Patients who experienced a subcutaneous recurrence were far less likely to undergo a secondary flap (p = 0.011). Factors associated with loss of the index reconstruction included lower body mass index (p = 0.009), pectoralis invasion (p = 0.05), and implant reconstruction (p = 0.03).

Conclusions: Detection and management of locoregional recurrence requires appropriate physical examination and imaging. Significant factors associated with failure to salvage the initial reconstruction included body mass index, plane of recurrence, and type of initial reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Latissimus Dorsi Myocutaneous Flap Is a Safe and Effective Method of Partial Breast Reconstruction in the Setting of Breast-Conserving Therapy Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 927e–935e Background: Reconstruction of partial breast defects in low-volume, nonptotic breasts can be challenging. The authors hypothesized that use of the latissimus dorsi flap in partial breast reconstruction is safe and associated with low complication and high patient satisfaction rates. Methods: All patients who underwent breast-conserving therapy and latissimus dorsi flap reconstruction from January 1, 2006, to December 31, 2016, were identified in a prospectively maintained database. Patient demographics, tumor characteristics, and complications were recorded. Patient-reported outcomes were assessed with the BREAST-Q breast-conserving therapy module. A group of plastic surgeons and laypersons used a five-point Likert scale to evaluate aesthetic outcomes in representative patients. Results: Forty-seven patients met the inclusion criteria. Median follow-up was 5.4 years. Most patients (93.6 percent) underwent immediate reconstruction. The mean resection volume was 219.5 cc (range, 70 to 877 cc). The overall complication rate was 8.5 percent. Grade 2 or 3 ptosis (OR, 1.21; 95 percent CI, 1.0 to 1.46; p = 0.03), smoking (OR, 13.1; 95 percent CI, 1.2 to 143.2; p = 0.03), and multicentric tumor (OR, 1.23; 95 percent CI, 1.04 to 1.64; p = 0.02) were associated with a higher complication rate. Ductal carcinoma in situ was associated with reoperation for positive margins (OR, 14.4; 95 percent CI, 2.1 to 100; p = 0.009). Of particular interest, patient-reported outcomes were favorable, with the highest rated domains being Satisfaction with Breasts (61; interquartile range, 37 to 77), Psychosocial Well-being (87; interquartile range, 63 to 100), and Physical Well-being (87; interquartile range, 81 to 100). The median aesthetic score was 4 (of 5). Conclusions: This is the first study to date using the BREAST-Q to assess patient-reported outcomes associated with the latissimus dorsi flap for partial breast reconstruction. The flap is safe and effective for reconstruction in the setting of breast-conserving therapy, providing aesthetically pleasing results with high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Latissimus Dorsi Myocutaneous Flap Is a Safe and Effective Method of Partial Breast Reconstruction in the Setting of Breast-Conserving Therapy

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 927e–935e

Background: Reconstruction of partial breast defects in low-volume, nonptotic breasts can be challenging. The authors hypothesized that use of the latissimus dorsi flap in partial breast reconstruction is safe and associated with low complication and high patient satisfaction rates. Methods: All patients who underwent breast-conserving therapy and latissimus dorsi flap reconstruction from January 1, 2006, to December 31, 2016, were identified in a prospectively maintained database. Patient demographics, tumor characteristics, and complications were recorded. Patient-reported outcomes were assessed with the BREAST-Q breast-conserving therapy module. A group of plastic surgeons and laypersons used a five-point Likert scale to evaluate aesthetic outcomes in representative patients.

Results: Forty-seven patients met the inclusion criteria. Median follow-up was 5.4 years. Most patients (93.6 percent) underwent immediate reconstruction. The mean resection volume was 219.5 cc (range, 70 to 877 cc). The overall complication rate was 8.5 percent. Grade 2 or 3 ptosis (OR, 1.21; 95 percent CI, 1.0 to 1.46; p = 0.03), smoking (OR, 13.1; 95 percent CI, 1.2 to 143.2; p = 0.03), and multicentric tumor (OR, 1.23; 95 percent CI, 1.04 to 1.64; p = 0.02) were associated with a higher complication rate. Ductal carcinoma in situ was associated with reoperation for positive margins (OR, 14.4; 95 percent CI, 2.1 to 100; p = 0.009). Of particular interest, patient-reported outcomes were favorable, with the highest rated domains being Satisfaction with Breasts (61; interquartile range, 37 to 77), Psychosocial Well-being (87; interquartile range, 63 to 100), and Physical Well-being (87; interquartile range, 81 to 100). The median aesthetic score was 4 (of 5).

Conclusions: This is the first study to date using the BREAST-Q to assess patient-reported outcomes associated with the latissimus dorsi flap for partial breast reconstruction. The flap is safe and effective for reconstruction in the setting of breast-conserving therapy, providing aesthetically pleasing results with high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Perfusion Zones of Extended Transverse Skin Paddles in Muscle-Sparing Latissimus Dorsi Myocutaneous Flaps for Breast Reconstruction

Perfusion Zones of Extended Transverse Skin Paddles in Muscle-Sparing Latissimus Dorsi Myocutaneous Flaps for Breast Reconstruction

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 920e–926e

Background: The authors report their experience using extended transversely oriented skin paddles in muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction as an alternative to thoracodorsal artery perforator flaps.

Methods: A retrospective review was conducted of patients who underwent muscle-sparing latissimus dorsi flap pedicled breast reconstruction from January of 2009 to July of 2014 with at least 3-month follow-up. Surgical outcomes and complications were analyzed.

Results: Fifty-three patients underwent a total of 81 muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction. Extended transversely oriented skin paddles ranged from 7 to 9 cm vertically by 25 to 35 cm horizontally and were perfused by a strip of latissimus dorsi muscle that was approximately 25 percent of the total muscular volume. Twenty patients had indocyanine green angiography revealing three distinct zones of perfusion in the extended transversely oriented skin paddles. The area of earliest perfusion (designated zone 1) was directly over the muscle containing the perforators. The second best area of perfusion (zone 2) was lateral to the muscle (toward the axilla). The last and relatively least well-perfused area (zone 3) was medial to the muscle (toward the spine). Zone 3 still had adequate viability. There were no flap losses. Minor complications included wound infection [six of 81 (7.4 percent)], fat necrosis [three of 81 (3.7 percent)], and seroma [four of 81 (4.9 percent)].

Conclusions: Muscle-sparing latissimus dorsi pedicled flaps with extended transversely oriented skin paddles are reliable alternatives to thoracodorsal artery perforator flaps for breast reconstruction. Three zones of perfusion were delineated in the extended transversely oriented skin paddles on indocyanine green imaging, and all three zones were viable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis

Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis

Plastic and Reconstructive Surgery:  May 2019 - Volume 143 - Issue 5 - p 906e–919e

Background: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method.

Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed.

Results: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period. Conclusions: For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.

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.

[Comment] Assessment of breast cancer risk: which tools to use?

[Comment] Assessment of breast cancer risk: which tools to use?

by Montserrat Garcia-Closas, Nilanjan Chatterjee  

The Lancet Oncology: Comment, Volume 20 issue 4, p.463-464, April 01 2019

Risk-assessment tools are used in routine clinical practice to identify women at increased risk of breast cancer and to inform counselling about lifestyle changes, genetic testing, screening timing or modality, and eligibility for risk-reducing drugs or surgery. In The Lancet Oncology, Mary Beth Terry and colleagues1 report a comparative validation of four models—the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm model (BOADICEA), BRCAPRO, the Breast Cancer Risk Assessment Tool (BCRAT), and the International Breast Cancer Intervention Study model (IBIS)—used in clinical practice to provide absolute risk estimates for breast cancer on the basis of different sets of factors.

Theories of Etiopathogenesis of Breast Implant–Associated Anaplastic Large Cell Lymphoma

Theories of Etiopathogenesis of Breast Implant–Associated Anaplastic Large Cell Lymphoma

by Rastogi, Pratik; Riordan, Edward; Moon, David; Deva, Anand K.  

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3S - p 23S–29S

Summary: Breast implant–associated anaplastic large cell lymphoma is a malignancy of T lymphocytes that is associated with the use of textured breast implants in both esthetic and reconstructive surgeries. Patients typically present with a delayed seroma 8–10 years following implantation or—less commonly—with a capsular mass or systemic disease. Current theories on disease pathogenesis focus on the interplay among textured implants, Gram-negative bacteria, host genetics, and time. The possible roles of silicone leachables and particles have been less well substantiated. This review aims to synthesize the existing scientific evidence regarding breast implant–associated anaplastic large cell lymphoma etiopathogenesis.

Utility of Two Surgical Techniques Using a Lateral Intercostal Artery Perforator Flap after Breast-Conserving Surgery: A Single-Center Retrospective Study

Utility of Two Surgical Techniques Using a Lateral Intercostal Artery Perforator Flap after Breast-Conserving Surgery: A Single-Center Retrospective Study

Kim, Jae Bong; Eom, Jeung Ryeol; Lee, Jeong Woo; Lee, Jeeyeon; Park, Ho Yong; Yang, Jung Dug  

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3 - p 477e–487e

Background: Immediate partial breast reconstruction after breast-conserving surgery has become a new paradigm in treating breast cancer. Among the volume replacement techniques used for small to moderate-sized breasts, the perforator flap method has many advantages. The authors present anatomical studies and two surgical techniques using lateral intercostal artery perforator flaps. Methods: Data from 40 patients who underwent breast reconstruction using the lateral intercostal artery perforator flap between January of 2011 and June of 2016 were included. The authors conducted comparative analyses of the propeller flap and the turnover flap. They used three-dimensional computed tomography in lateral intercostal artery perforator flap anatomical studies, analyzing the distribution probability of the dominant perforator, the vertical distance from the axillary fold, and the horizontal distance from the anterior border of the latissimus dorsi.

Results: The most dominant perforator used for lateral intercostal artery perforator flaps was the sixth lateral intercostal artery perforator (43.6 percent of cases), followed by the seventh lateral intercostal artery perforator (39.1 percent of cases); their mean distances from the latissimus dorsi and the axillary folds were determined and reported. Complications included three cases requiring additional treatment for fat necrosis (propeller method, two cases; turnover method, one case) and venous congestion in only two cases that used the propeller method. Cosmetic satisfaction was 90 percent or greater for both techniques, indicating that results were rated as either excellent or good. Conclusion: The authors believe that their study results can broaden the application of partial breast reconstruction by using the lateral intercostal artery perforator flap after breast-conserving surgery, with three-dimensional computed tomography for anatomical studies, and using one of the authors’ two described surgical techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The changes of quality of life and their correlations with psychosocial factors following surgery among women with breast cancer from the post-surgery to post-treatment survivorship

The changes of quality of life and their correlations with psychosocial factors following surgery among women with breast cancer from the post-surgery to post-treatment survivorship

by Fei-Hsiu Hsiao, Wen-Hung Kuo, Guey-Mei Jow, Ming-Yang Wang, King-Jen Chang, Yu-Ming Lai, Yu-Ting Chen, Chiun-Sheng Huang

The Breast: April 2019, Volume 44, pages 59-65

This 14-month study aimed to examine the changes of quality of life following breast cancer surgery and associations of such changes with depression and anxiety levels, and protective factors (attachment styles in close relationship, and meaning in life) based on positive psychology theory.

Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management

Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management

by Anna Michelotti, Marco Invernizzi, Gianluca Lopez, Daniele Lorenzini, Francesco Nesa, Alessandro De Sire, Nicola Fusco  

The Breast: April 2019, Volume 44, Pages 15-23

Breast cancer related lymphedema (BCRL) develops as a consequence of surgical treatment and/or radiation therapy in a significant number of breast cancer patients. The etiology of this condition is multifactorial and has not yet been completely elucidated. Risk factors include high body mass index, radical surgical procedures (i.e. mastectomy and axillary lymph node dissection), number of lymph nodes removed and number of metastatic lymph nodes, as well as nodal radiation, and chemotherapy. However, these predisposing factors explain only partially the BCRL occurrence, suggesting the possible involvement of individual determinants.

Risk factors for metachronous contralateral breast cancer: A systematic review and meta-analysis

Risk factors for metachronous contralateral breast cancer: A systematic review and meta-analysis

by Delal Akdeniz, Marjanka K. Schmidt, Caroline M. Seynaeve, Danielle McCool, Daniele Giardiello, Alexandra J. van den Broek, Michael Hauptmann, Ewout W. Steyerberg, Maartje J. Hooning  

The Breast: April 2019, Volume 44, pages 1-14

The risk of developing metachronous contralateral breast cancer (CBC) is a recurrent topic at the outpatient clinic. We aimed to provide CBC risk estimates of published patient, pathological, and primary breast cancer (PBC) treatment-related factors.

Current Risk Estimate of Breast Implant–Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants

Current Risk Estimate of Breast Implant–Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants

 by Collett, David J.; Rakhorst, Hinne; Lennox, Peter; Magnusson, Mark; Cooter, Rodney; Deva, Anand K.  

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3S - p 30S–40S

Background: With breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL. Methods: All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed. Results: Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the “population” (implant type and characteristics) examined and increased awareness of the disease.

Conclusions: Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined—driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).

Breast Implant Illness: A Way Forward

Breast Implant Illness: A Way Forward

by Magnusson, Mark R.; Cooter, Rod D.; Rakhorst, Hinne; McGuire, Patricia A.; Adams, William P. Jr; Deva, Anand K.

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3S - p 74S–81S

Summary: The link between breast implants and systemic disease has been reported since the 1960s. Although many studies have looked at either supporting or refuting its existence, the issue still persists and has now been labeled “breast implant illness.” The rise of patient advocacy and communication through social media has led to an increasing number of presentations to plastic surgeons. This article summarizes the history of breast implants and systemic disease, critically analyzes the literature (and any associated deficiencies), and suggests a way forward through systematic scientific study.