Synergistic Interaction Increases Complication Rates following Microvascular Breast Reconstruction

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.

Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes

Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes

The Breast: August 2019 Volume 46, Pages 144–156

by Chi Wei Mok, Hung-Wen Lai 

 To review current literature on the outcomes, techniques and trend of endoscopic-assisted breast surgery (EABS) in the management of breast cancer over a 20 years period Materials and Methods: Literature search was performed using PubMed/Medline database from 1st January 1998 to 31st December 2018 using the terms “endoscopy”, “endoscopy-assisted”, “breast cancer”, “mastectomy” and “breast conserving surgery”. Additional studies were also identified by reviewing references of relevant articles. Only case series and cohort studies were included in this review.

Breast cancer follow-up after a primary diagnosis: A confused picture

Breast cancer follow-up after a primary diagnosis: A confused picture

The Breast: August 2019 Volume 46, Pages 97–100

by Susanne Cruickshank, Matthew Barber 

The follow-up care of people diagnosed with early breast cancer varies across the world. In the UK, services have evolved in an ad hoc way, with no standardized approach nationally. Some people are seen face to face at regular intervals, others are discharged at two years, while others are followed up over the telephone. This is creating confusion for patients as to what is best practice. The lack of evidence to support intensive surveillance is frequently cited as the main reason to reduce or indeed review the benefits of face to face clinical consultations in the hospital/community setting.

About the French prohibition of textured breast implants: is it justified or over-cautious? The EUSOMA, ESSO/BRESSO position

About the French prohibition of textured breast implants: is it justified or over-cautious? The EUSOMA, ESSO/BRESSO position

The Breast: August 2019 Volume 46, Pages 95–96

by M.J. Cardoso, L. Biganzoli, I.T. Rubio, Leidenius M, Curigliano G, Cutuli B, Marotti L, T. Kovacs, L. Wyld 

After the publication of the EUSOMA position regarding breast implant associated anaplastic large cell lymphoma (BIA-ALCL) and the use of textured implants in January 2019 [1], the medical devices regulatory authority in France, the ANSM (National Agency of Medicine and Health Products), has recently banned all use of textured surface breast implants. This decision was based on concerns about the risk of BIA ALCL which may be more likely in women with textured versus smooth surfaced implants [2].

Reducing seroma formation and its sequelae after mastectomy by closure of the dead space: The interim analysis of a multi-center, double-blind randomized controlled trial (SAM trial)

Reducing seroma formation and its sequelae after mastectomy by closure of the dead space: The interim analysis of a multi-center, double-blind randomized controlled trial (SAM trial)

The Breast: August 2019 Volume 46, Pages 81–86

by Renée W.Y. Granzier, James van Bastelaar, Sander M.J. van Kuijk, Kim F.H. Hintzen, Cathelijne Heymans, Lotte L.B. Theunissen, Els R.M. van Haaren, Alfred Janssen, Geerard L. Beets, Yvonne L.J. Vissers

The main objective of this double-blind randomized controlled trial (RCT) was to assess seroma formation and its sequelae in patients undergoing mastectomy. Patients were randomized into one of three groups in which different wound closure techniques were applied: 1) conventional wound closure without flap fixation (CON) 2) flap fixation using sutures (FF–S) and 3) flap fixation using an adhesive tissue glue (FF-G).

Current knowledge of risk reducing mastectomy: Indications, techniques, results, benefits, harms

Current knowledge of risk reducing mastectomy: Indications, techniques, results, benefits, harms

The Breast: August 2019 Volume 46, Pages 48–51

by Andrew D. Baildam 

The last twenty years have seen a complete change in society's attitude to the strategy of risk reduction of breast cancer in high-risk individuals by means of proactive mastectomy. Once termed ‘prophylactic mastectomy’, risk reducing mastectomy (RRM) was considered two decades ago not only extreme, but in some quarters almost unethical. RRM is now commonly undertaken in specialist breast units for women at high individual breast cancer risk, by virtue of an inherited breast cancer related gene mutation or from calculated high statistical risk from family history data, and the efficacy of RRM in reducing subsequent incident diagnoses of breast cancer has been published from a number of centres.

Efficacy of extended aromatase inhibitors for hormone-receptor–positive breast cancer: A literature-based meta-analysis of randomized trials

Efficacy of extended aromatase inhibitors for hormone-receptor–positive breast cancer: A literature-based meta-analysis of randomized trials

The Breast: August 2019 Volume 46, Pages 19–24

by S.P. Corona, G. Roviello, C. Strina, M. Milani, S. Madaro, D. Zanoni, G. Allevi, S. Aguggini, M.R. Cappelletti, M. Francaviglia, C. Azzini, A. Cocconi, M. Sirico, M. Bortul, F. Zanconati, F. Giudici, P. Rosellini, F. Meani, O. Pagani, D. Generali

Endocrine treatment with Tamoxifen and aromatase inhibitors (AIs) is a staple in the management of hormone receptor positive breast cancer (HR + BC). It has become clear that HR + BC carries a consistent risk of relapse up to 15 years post-diagnosis. While increasing evidence supports the use of extended adjuvant Tamoxifen over 5 years, controversial data are available on the optimal duration of extended AIs adjuvant treatment.We performed a meta-analysis to assess the real impact of extended adjuvant therapy with AIs on disease-free survival (DFS).

De-escalation of complexity in oncoplastic breast surgery: Case series from a specialized breast center

De-escalation of complexity in oncoplastic breast surgery: Case series from a specialized breast center

The Breast: August 2019Volume 46, Pages 12–18

by G. Catanuto, A. Khan, V. Ursino, E. Pietraforte, G. Scandurra, C. Ravalli, N. Rocco, M.B. Nava, F. Catalano 

Oncoplastic breast surgery has evolved the surgical treatment of breast cancer over the past two decades. This practice still lacks validation and poses several dilemmas in terms of safety, local and systemic control, timing of adjuvant treatments and cost-effectiveness. Our case series investigates the effects of a reduced surgical complexity on cosmetic results and quality of life.

Patient-reported health problems and healthcare use after treatment for early-stage breast cancer

Patient-reported health problems and healthcare use after treatment for early-stage breast cancer

The Breast: August 2019 Volume 46, Pages 4–11

by K.M. de Ligt, M. Heins, J. Verloop, C.H. Smorenburg, J.C. Korevaar, S. Siesling 

A clear picture of treatment-related health problems following breast cancer treatment is useful in anticipating the informational and other needs of patients during follow-up. This study aimed to identify treatment-related health problems in breast cancer patients up to five years after diagnosis. Secondly, the use of care associated with these health problems was identified.

A New and Innovative Method of Preoperatively Planning and Projecting Vascular Anatomy in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

A New and Innovative Method of Preoperatively Planning and Projecting Vascular Anatomy in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1151e–1158e

by Hummelink, Stefan; Hoogeveen, Yvonne L.; Schultze Kool, Leo J.; Ulrich, Dietmar J. O. 

Background: In deep inferior epigastric perforator (DIEP) flap breast reconstructions, a free tissue flap from the abdomen is shaped into a breast and transferred to the thorax. Survival of this free flap relies on minuscule blood vessels, so-called perforators, providing blood supply to this newly molded breast. Preoperative mapping of these randomly distributed blood vessels is essential to avoid complications. The purpose of this study was to investigate whether the preoperative projection of a virtual three-dimensional plan based on computed tomographic angiography onto the abdomen leads to more correctly identified perforator locations and less operative time spent on dissecting the free flap compared to the commonly used Doppler ultrasound planning method.

Methods: The authors conducted a randomized, open, single-center, superiority trial in patients undergoing DIEP flap breast reconstruction with 1-week follow-up. Randomized participants were 60 adults (projection method, n = 33; Doppler method, n = 27) undergoing DIEP flap breast reconstruction without lymph node transfer.

Results: Sixty patients provided 69 DIEP flaps for analysis. The projection method is capable preoperatively of displaying significantly more perforators compared to the Doppler method (61.7 ± 7.3 percent versus 41.2 ± 8.2 percent, respectively; p = 0.020)). During the procedure, flap harvest time is decreased by 19 minutes (136 ± 7 minutes versus 155 ± 7 minutes; p = 0.012). Complications were comparable across both groups.

Conclusion: Not only can more perforators be identified intraoperatively using the projection method compared with Doppler ultrasound, there is also a significant time reduction in harvesting the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Stacked Lateral Thigh Perforator Flap as a Novel Option for Autologous Breast Reconstruction

Stacked Lateral Thigh Perforator Flap as a Novel Option for Autologous Breast Reconstruction

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1601–1604

by Tessler, Oren; Guste, John; Bartow, Matthew J.; Torabi, Radbeh; Gimenez, Alejandro; Patel, Shukan B.; Matatov, Tim; Torabi, Rozbeh; St. Hilaire, Hugo; Allen, Bob

Background: Autologous breast reconstruction using perforator flaps offers excellent outcomes, minimizes donor-site morbidity, and allows for precise donor-site selection. The deep inferior epigastric artery perforator, profunda artery perforator, and gluteal artery perforator flaps along with the stacked flap technique are the most common options. This study reports the first series of the stacked lateral thigh perforator flap.

Methods: A retrospective review of all stacked lateral thigh perforator flaps done by a single group of surgeons was performed. Demographics, flap weights, complications, indications, and surgical technique were tabulated for each patient.

Results: Eight female patients with a history of breast cancer underwent delayed unilateral breast reconstruction with stacked lateral thigh perforator flaps for a total of 16 flaps. Mean patient age, body mass index, flap weight, and stacked flap weight were 47.3 years, 26.2 kg/m2, 333.1 g, and 666.1 g, respectively. Microsurgical revascularization was completed in anterograde and retrograde fashion to the internal mammary vasculature. Flap survival was 100 percent and one subsequent flap revision was performed. Two patients developed a seroma at the donor site. Indications included insufficient abdominal tissue, prominent lateral thigh lipodystrophy, prior abdominal surgery, and failed prior abdominally based autologous reconstruction.

Conclusions: This series demonstrates that the lateral thigh perforator flap is a reliable and effective option for a stacked breast reconstruction. Its ease of harvest (stemming from reliable anatomy), straightforward dissection, and intraoperative positioning make it an appealing flap option. The stacked lateral thigh perforator flap allows the reconstructive surgeon to tailor breast reconstruction to the patient, focusing on body habitus and minimizing morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tissue-Based Planning and Technique for Breast Augmentation with Anatomical Implants

Tissue-Based Planning and Technique for Breast Augmentation with Anatomical Implants

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1634–1636

by Adams, William P. Jr; Afrooz, Paul N.; Stuzin, James M. 

Summary: Breast augmentation with anatomical implants offers several potential advantages. Tissue-based planning is patient specific and essential in choosing the correct dimensions of an implant, thereby providing greater control in breast shape following augmentation. This video vignette demonstrates tissue-based planning in a patient with a constricted breast, allowing the surgeon to accurately choose the proper implant dimensions, which correct the constriction while providing aesthetic control of breast shape. Operative techniques of precise pocket formation, prospective hemostasis, and judging the aesthetic contour following implant insertion are demonstrated.

Evolution of the Surgical Technique for “Breast in a Day” Direct-to-Implant Breast Reconstruction: Transitioning from Dual-Plane to Prepectoral Implant Placement

Evolution of the Surgical Technique for “Breast in a Day” Direct-to-Implant Breast Reconstruction: Transitioning from Dual-Plane to Prepectoral Implant Placement

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1547–1556

Background: Direct-to-implant breast reconstruction offers the intuitive advantages of shortening the reconstructive process and reducing costs. In the authors’ practice, direct-to-implant breast reconstruction has evolved from dual-plane to prepectoral implant placement. The authors sought to understand postoperative complications and aesthetic outcomes and identify differences in the dual-plane and prepectoral direct-to-implant subcohorts.

Methods: A retrospective review of a prospectively maintained database was conducted from November of 2014 to March of 2018. Postoperative complication data, reoperation, and aesthetic outcomes were reviewed. Aesthetic outcomes were evaluated by a blinded panel of practitioners using standardized photographs.

Results: One hundred thirty-four direct-to-implant reconstructions were performed in 81 women: 42.5 percent were dual-plane (n = 57) and 57.5 percent were prepectoral (n = 77). Statistical analysis was limited to patients with at least 1 year of follow-up. Total complications were low overall (8 percent), although the incidence of prepectoral complications [n = 1 (2 percent)] was lower than the incidence of dual-plane complications [n = 7 (12 percent)], with the difference approaching statistical significance (p = 0.07). Panel evaluation for aesthetic outcomes favored prepectoral reconstruction. Pectoralis animation deformity was completely eliminated in the prepectoral cohort.

Conclusions: The authors present the largest comparative direct-to-implant series using acellular dermal matrix to date. Transition to prepectoral direct-to-implant reconstruction has not resulted in increased complications, degradation of aesthetic results, or an increase in revision procedures. Prepectoral reconstruction is a viable reconstructive option with elimination of animation deformity and potential for enhanced aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

[Comment] Tomosynthesis in breast screening: great expectations?

[Comment] Tomosynthesis in breast screening: great expectations?

The Lancet. Oncology, ISSN: 1474-5488, Vol: 20, Issue: 6, Page: 745-746

Digital breast tomosynthesis, also known as three-dimensional mammography, has been under investigation as a replacement for or complement to two-dimensional (2D) digital mammography in breast cancer screening for some years, with several prospective, population-based trials reporting increased cancer detection.1 So far, published studies have been of paired design, in which each woman is her own control—ie, imaged with both digital mammography and digital breast tomosynthesis, read and reported in separate reading groups with either stand-alone digital breast tomosynthesis, or digital breast tomosynthesis in combination with digital mammography or so-called synthetic digital mammography in the digital tomosynthesis group.

[Articles] Two-view digital breast tomosynthesis versus digital mammography in a population-based breast cancer screening programme (To-Be): a randomised, controlled trial

[Articles] Two-view digital breast tomosynthesis versus digital mammography in a population-based breast cancer screening programme (To-Be): a randomised, controlled trial

The Lancet. Oncology, ISSN: 1474-5488, Vol: 20, Issue: 6, Page: 795-805

This study indicated that digital breast tomosynthesis including synthetic 2D mammograms was not significantly different from standard digital mammography as a screening tool for the detection of breast cancer in a population-based screening programme. Economic analyses and follow-up studies on interval and consecutive round screen-detected breast cancers are needed to better understand the effect of digital breast tomosynthesis in population-based breast cancer screening.

Unconventional Perfusion Flaps in the Experimental Setting: A Systematic Review and Meta-Analysis

Unconventional Perfusion Flaps in the Experimental Setting: A Systematic Review and Meta-Analysis

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1003e–1016e

Background: Unconventional perfusion flaps offer multiple potential advantages compared with traditional flaps. Although there are numerous experimental articles on unconventional perfusion flaps, the multiple animal species involved, the myriad vascular constructions used, and the frequently conflicting data reported make synthesis of this information challenging. The main aim of this study was to perform a systematic review and meta-analysis of the literature on the experimental use of unconventional perfusion flaps, to identify the best experimental models proposed and to estimate their global survival rate.

Methods: The authors performed a systematic review and meta-analysis of all articles written in English, French, Italian, Spanish, and Portuguese on the experimental use of unconventional perfusion flaps and indexed to PubMed from 1981 until February 1, 2017.

Results: A total of 68 studies were found, corresponding to 86 optimized experimental models and 1073 unconventional perfusion flaps. The overall unconventional perfusion flap survival rate was 90.8 percent (95 percent CI, 86.9 to 93.6 percent; p < 0.001). The estimated proportion of experimental unconventional perfusion flaps presenting complete survival or nearly complete survival was 74.4 percent (95 percent CI, 62.1 to 83.7 percent; p < 0.001). The most commonly reported animal species in the literature were the rabbit (57.1 percent), the rat (26.4 percent), and the dog (14.3 percent). No significant differences were found in survival rates among these species, or among the diverse vascular patterns used.

Conclusion: These data do not differ significantly from those reported regarding the use of unconventional perfusion flaps in human medicine, suggesting that rabbit, rat, and canine experimental unconventional perfusion flap models may adequately mimic the clinical application of unconventional perfusion flaps.

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.