Thursday, 5 July 2018

Nipple-Sparing Mastectomy Incisions for Cancer Extirpation Prospective Cohort Trial: Perfusion, Complications, and Patient Outcomes



by Odom, Elizabeth B.; Parikh, Rajiv P.; Um, Grace; Kantola, Simone W.; Cyr, Amy E.; Margenthaler, Julie A.; Tenenbaum, Marissa M.; Myckatyn, Terence M.  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 13–26

Background: Nipple-sparing mastectomy offers several advantages for women seeking postmastectomy breast reconstruction, but compromised skin and nipple perfusion may lead to skin and nipple necrosis. It is unclear whether the incisional approach contributes to these complications; therefore, the purpose of this study was to compare the impact of incision type on outcomes in patients undergoing nipple-sparing mastectomy. Methods: This is a prospective cohort study of patients undergoing nipple-sparing mastectomy with prosthetic breast reconstruction through an inframammary fold versus a lateral radial incision. Skin and nipple perfusion as represented by fluorescence intensity, mammometric parameters, patient-reported outcomes, and clinical outcomes were analyzed and compared for the two cohorts, and multivariable logistic regression models were performed to evaluate the effects of covariates on outcomes. Results: Seventy-nine patients were studied: 55 in the inframammary fold cohort and 24 in the lateral radial cohort. The inframammary fold group had significantly less fluorescence intensity to the inferior (21.9 percent versus 36.9 percent; p = 0.001) and lateral portions of breast skin (23.1 percent versus 40.7 percent; p = 0.003) after reconstruction. Decreased fluorescence intensity was associated with smoking, decreased mean arterial pressure, and greater specimen weight. Postreconstruction breast volumes were increased over preoperative volumes in the inframammary fold group (38.3 percent) versus the lateral radial (31.2 percent) group; however, patients with a lateral radial incision had a greater increase in satisfaction with their breasts and psychosocial well-being. Conclusions: There are significant differences in patient-reported outcomes and final breast volumes based on the incisional approach to nipple-sparing mastectomy. These data can be used to guide providers and counsel patients considering nipple-sparing mastectomy with prosthetic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

IDEAL IMPLANT Structured Breast Implants: Core Study Results at 6 Years



by Nichter, Larry S.; Hardesty, Robert A.; Anigian, Gregg M.  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 66–75

Background: The structured breast implant uses different technology than saline or silicone gel implants, making it a third type of implant. The U.S. Food and Drug Administration and Health Canada granted approval in November of 2014. This implant is filled with saline but has an internal structure consisting of a series of nested shells that support the upper pole when upright and control fluid movement. It combines certain key features and benefits of saline and silicone gel implants. As with saline, the filler is only saline, which women like for peace of mind in case of rupture/deflation. As with silicone gel, it has a natural feel, but without the risk of silent rupture and U.S. Food and Drug Administration–recommended magnetic resonance imaging scans—women can simply look in the mirror and know their implants are intact. Methods: This U.S. trial enrolled 502 women: 399 primary augmentations and 103 replacements of existing augmentation implants. Investigators were 45 American Board of Plastic Surgery–certified plastic surgeons at 35 sites. Of the 502 women enrolled, 438 (87.3 percent) completed 6-year follow-up visits, a higher percentage than other Core breast implant trials. Results: At 6 years, patient satisfaction was 89.7 percent for primary and 91.6 percent for replacement augmentations; surgeon satisfaction was 92.6 percent for primary and 94.0 percent for replacement augmentation. Kaplan-Meier adverse event rates were as follows: Baker grade III and IV capsular contracture, 5.7 percent for primary and 11.5 percent for replacement augmentation; and rupture/deflation, 1.8 percent for primary and 4.7 percent for replacement augmentation. Conclusion: Six-year results from 438 women show that the structured breast implant has high patient and surgeon satisfaction, a low rate of capsular contracture, and a low rate of rupture/deflation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Gender Differences in the Professional and Personal Lives of Plastic Surgeons



by Furnas, Heather J.; Garza, Rebecca M.; Li, Alexander Y.; Johnson, Debra J.; Bajaj, Anureet K.; Kalliainen, Loree K.; Weston, Jane S.; Song, David H.; Chung, Kevin C.; Rohrich, Rod J.  


Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 252–264

Background: Although the number of women becoming plastic surgeons has increased during the past six decades, in comparison with the current gender parity in medical schools, plastic surgery still attracts disproportionately more men. Previous studies have shown disparities in the professional and personal lives of female and male plastic surgeons. A survey study was conducted to identify current challenges women and men encounter in the pursuit of a plastic surgical career to guide remedial strategies. Methods: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates for comparison between sexes. Differences were tested by the Fisher’s exact and chi-square tests. Results: Women were more likely than men to have experienced sexism or bias. Women were less likely to be married; be satisfied with work-life balance; or feel recognized for ideas, authorship, promotions, or raises. Women felt that their sex was a disadvantage in career advancement, with one exception: unlike men, women felt many patients chose them because of their sex. Despite these challenges, over 80 percent of all plastic surgeons were satisfied with their choice of career. Conclusions: Traditions and gender bias create disparities in the personal and professional lives of female and male plastic surgeons. Our specialty must make concrete changes to promote all plastic surgeons, both women and men, to thrive personally and professionally.

Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction: The “1–2–3 Rule”



by Lee, Christina Dami; Butterworth, James; Stephens, Robert E.; Wright, Barth; Surek, Christopher  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 28–36

Background: Postmastectomy breast reconstruction provides psychosocial benefits in self-esteem, sexuality, and quality of life. Autologous procedures yield the highest overall patient satisfaction compared with implant-based breast reconstruction as the gold standard. The internal mammary vessels are the preferred recipient vessels for free flap breast reconstruction. The purpose of this study is to provide surgeons with a reliable method for locating the vessels intraoperatively. Methods: The internal mammary vessels were dissected bilaterally on 30 cadaveric specimens. Distances from the lateral sternal borders and the costochondral junctions to the internal mammary vessels at the second, third, and fourth costal levels were recorded. Descriptive bifurcation patterns were recorded. Initial dissection practicums were performed using the proposed safer dissection zone according to quantitative data. Results: Sixty internal mammary arteries and 120 internal mammary veins were studied at three costal levels, resulting in 180 sets of measurements. Distances from the lateral sternal border to the medial internal mammary vein were 6.12, 9.04, and 10.45 mm at costal levels 2, 3, and 4, respectively. Mean distances between costochondral junctions and internal mammary arteries were 12.80, 24.78, and 33.28 mm at costal levels 2, 3, and 4, respectively. Most internal mammary vein bifurcated at the third costal level, and the left side bifurcated higher than the right. Dissection practicums revealed that the proposed dissection zone was consistently reliable in locating the vessels. Conclusions: This study provides mean measurements from common bony landmarks to the internal mammary vessels, equipping surgeons with a reliable zone of dissection for recipient vessel exposure. This may decrease morbidity and improve outcomes in autologous breast reconstructions.

Prepectoral Implant-Based Breast Reconstruction with Postmastectomy Radiation Therapy



 by Elswick, Sarah M.; Harless, Christin A.; Bishop, Sarah N.; Schleck, Cathy D.; Mandrekar, Jay; Reusche, Ryan D.; Mutter, Robert W.; Boughey, Judy C.; Jacobson, Steven R.; Lemaine, Valerie  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 1–12

Background: Two-stage subpectoral implant-based breast reconstruction is the most common method for breast reconstruction. Recent advances in surgical techniques and technology have made prepectoral implant-based breast reconstruction feasible. There are limited data on outcomes after prepectoral implant-based breast reconstruction and postmastectomy radiation therapy. Methods: A retrospective review of consecutive patients undergoing immediate two-stage prepectoral implant-based breast reconstruction with postmastectomy radiation therapy was performed. Outcomes of irradiated breasts were compared with nonirradiated breasts in bilateral cases. Results: Ninety-three cases of prepectoral implant-based breast reconstruction in 54 women who underwent immediate two-stage reconstruction (39 bilateral and 15 unilateral) and unilateral postmastectomy radiation therapy were identified. Mean follow-up was 19 months from mastectomy and tissue expander reconstruction and 9 months from implant placement. Crude complication rates in irradiated versus nonirradiated sides were as follows: surgical-site infection, 18.5 percent versus 7.7 percent; seroma, 5.6 percent versus 5.1 percent; mastectomy skin flap necrosis, 1.9 percent versus 2.6 percent; wound dehiscence, 1.9 percent versus 7.7 percent; capsular contracture, 1.9 percent versus 0 percent; hematoma, 1.9 percent versus 2.6 percent; and extrusion, 1.9 percent versus 0 percent. On univariate analysis, there were no risk factors associated with any complication, including radiation therapy, surgical-site infection, unplanned readmissions, and unplanned return to the operating room. To date, reconstruction has been completed in 96 percent of patients, with successful implant-based breast reconstruction in 81 breasts (45 irradiated breasts and 36 nonirradiated breasts). Conclusions: Early data of prepectoral implant-based breast reconstruction in patients with postmastectomy radiation therapy show promising results. Postmastectomy radiation therapy should not be an absolute contraindication to prepectoral implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Efficacy and safety of ABP 980 compared with reference trastuzumab in women with HER2-positive early breast cancer (LILAC study): a randomised, double-blind, phase 3 trial




 by Gunter von Minckwitz, Marco Colleoni, Hans-Christian Kolberg, Serafin Morales, Patricia Santi, Zorica Tomasevic, Nan Zhang, Vladimir Hanes  

The Lancet Oncology, Vol 19, No. 7, p987-998, July 2018

Although the lower bounds of the 90% CIs for RR and risk difference showed non-inferiority, the upper bounds exceeded the predefined equivalence margins when based on local laboratory review of tumour samples, meaning that non-superiority was non-conclusive. In our sensitivity analyses based on central laboratory evaluation of tumour samples, estimates for the two drugs were contained within the predefined equivalence margins, indicating similar efficacy. ABP 980 and trastuzumab had similar safety outcomes in both the neoadjuvant and adjuvant phases of the study.

Ribociclib plus endocrine therapy for premenopausal women with hormone-receptor-positive, advanced breast cancer (MONALEESA-7): a randomised phase 3 trial



 by Debu Tripathy, Seock-Ah Im, Marco Colleoni, Fabio Franke, Aditya Bardia, Nadia Harbeck, Sara A Hurvitz, Louis Chow, Joohyuk Sohn, Keun Seok Lee, Saul Campos-Gomez, Rafael Villanueva Vazquez, Kyung Hae Jung, K Govind Babu, Paul Wheatley-Price, Michelino De Laurentiis, Young-Hyuck Im, Sherko Kuemmel, Nagi El-Saghir, Mei-Ching Liu, Gary Carlson, Gareth Hughes, Ivan Diaz-Padilla, Caroline Germa, Samit Hirawat, Yen-Shen Lu  

The Lancet Oncology Vol 19, No. 7, p904-915, July 2018

Ribociclib plus endocrine therapy improved progression-free survival compared with placebo plus endocrine therapy, and had a manageable safety profile in patients with premenopausal, HR-positive, HER2-negative, advanced breast cancer. The combination could represent a new first-line treatment option for these patients.


Prospective, Randomized, Controlled Comparison of Bupivacaine versus Liposomal Bupivacaine for Pain Management after Unilateral Delayed Deep Inferior Epigastric Perforator Free Flap Reconstruction



 by Gatherwright, James; Knackstedt, Rebecca W.; Ghaznavi, Amir M.; Bernard, Steven; Schwarz, Graham; Moreira, Andrea; Gurunluoglu, Raffi; Djohan, Risal  


Plastic and Reconstructive Surgery: June 2018 - Volume 141 - Issue 6 - p 1327–1330

Summary: Effective postsurgical analgesia is a critical aspect of patient recovery. The goal of this prospective, randomized, controlled, blinded study was to examine the effect that liposomal bupivacaine delivered by means of a transversus abdominis plane block has on pain control in women undergoing unilateral deep inferior epigastric perforator flap reconstruction. Institutional review board approval was granted for this prospective study. Patients were eligible if they were undergoing unilateral, delayed deep inferior epigastric perforator flap reconstruction. Patients were randomized to one of three groups: liposomal bupivacaine transversus abdominis plane block, or bupivacaine pain pump. Charts were reviewed for demographics, length of stay, and postoperative narcotic use. There were eight patients in the liposomal bupivacaine and bupivacaine transversus abdominis plane block groups and five patients in the pain pump group. A retrospective cohort of six patients who did not receive any intervention was included. Patients who received a liposomal bupivacaine transversus abdominis plane block used statistically significantly less intravenous and total postoperative narcotics in milligrams and milligrams per kilogram per day compared with all other cohorts. They were able to get out of bed at an earlier time point. Overall hospital costs were similar among the groups. This is the first study to investigate liposomal bupivacaine delivered as a transversus abdominis plane block in a prospective, randomized, blinded study in women undergoing unilateral, delayed, abdominally based autologous breast reconstruction. The authors were able to demonstrate a significant reduction in intravenous and total narcotic use when a liposomal bupivacaine transversus abdominis plane block was used. Future studies are needed to prospectively investigate the effect that liposomal bupivacaine would have on immediate and bilateral reconstructions.

The Impact of Mastectomy Weight on Reconstructive Trends and Outcomes in Nipple-Sparing Mastectomy: Progressively Greater Complications with Larger Breast Size



 by Frey, Jordan D.; Salibian, Ara A.; Karp, Nolan S.; Choi, Mihye  



Plastic and Reconstructive Surgery: June 2018 - Volume 141 - Issue 6 - p 795e–804e

Background: Reconstructive trends and outcomes for nipple-sparing mastectomy continue to be defined. The graduated impact of breast size and mastectomy weight remains incompletely evaluated. Methods: All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified. Demographics and outcomes were analyzed and stratified by mastectomy weight of 800 g or higher (large group), between 799 and 400 g (intermediate group), and less than 400 g (small group). Results: Of 809 nipple-sparing mastectomies, 66 (8.2 percent) had mastectomy weights of 800 g or higher, 328 (40.5 percent) had mastectomy weights between 799 and 400 g, and 415 nipple-sparing mastectomies (51.3 percent) had mastectomy weights less than 400 g. Nipple-sparing mastectomies in the large group were significantly more likely to be associated with major mastectomy flap necrosis (p = 0.0005), complete nipple-areola complex necrosis (p < 0.0001), explantation (p < 0.0001), cellulitis treated with oral (p = 0.0008) and intravenous (p = 0.0126) antibiotics, abscess (p = 0.0254), and seroma (p = 0.0126) compared with those in the intermediate group. Compared with small nipple-sparing mastectomies, patients in the large group had greater major mastectomy flap necrosis (p < 0.0001), complete (p < 0.0001) and partial (p = 0.0409) nipple-areola complex necrosis, explantation (p < 0.0001), cellulitis treated with oral (p < 0.0001) and intravenous (p < 0.0001) antibiotics, abscess (p = 0.0119), and seroma (p < 0.0001). Patients in the intermediate group were more likely to experience major (p < 0.0001) and minor (p < 0.0001) mastectomy flap necrosis, complete (p = 0.0015) and partial (p < 0.0001) nipple-areola complex necrosis, cellulitis treated with oral antibiotics (p = 0.0062), and seroma (p = 0.0248) compared with those undergoing small nipple-sparing mastectomies. Larger mastectomy weights were significant predictors of complications on logistic regression analysis. Conclusion: Reconstructive and ischemic complications in nipple-sparing mastectomy are progressively greater as mastectomy weight and breast size increase. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Toradol following Breast Surgery: Is There an Increased Risk of Hematoma?



by Nguyen, Brittany N.; Barta, Ruth J.; Stewart, Christine E.; Heinrich, Cherrie A.  

Plastic and Reconstructive Surgery: June 2018 - Volume 141 - Issue 6 - p 814e–817e

Background: Ketorolac tromethamine (Toradol), a nonsteroidal antiinflammatory drug, is used with increased frequency given its success in postoperative pain control and the subsequent decreased need for narcotics. Its use has been limited in plastic surgery for fear of postoperative bleeding and hematoma formation. In this study of breast surgery patients, the authors investigated whether ketorolac increased the risk of postoperative hematoma formation. Methods: After obtaining institutional review board approval, the authors retrospectively reviewed the records of patients undergoing breast surgery from January of 2012 through December of 2014. The authors compared the incidence of postoperative hematomas in patients who did, versus those who did not, receive ketorolac postoperatively. Results: For the entire cohort, the overall hematoma rate was 2.8 percent. Of the patients who received ketorolac, the rate was 3.5 percent; of those who did not, the rate was 2.5 percent. Of the breast reduction patients, the rate was 4 percent in those who received ketorolac versus 3.2 percent in those who did not. Of the breast reconstruction patients, the rate was 4 percent in those who received ketorolac versus 3.2 percent in those who did not. Conclusions: Recently, the high rates of prescribing postoperative narcotics have received increased attention. Aside from the risk of increased availability of narcotics in the community, the side effects can delay patient recovery. Ketorolac is controversial for postoperative pain control because of the potential risk of bleeding, but in the authors’ 3-year retrospective study, it was not associated with an increased risk of hematoma formation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Thursday, 17 May 2018

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?



Plastic and Reconstructive Surgery - Most Popular Articles by Frey, Jordan D.; Stranix, John T.; Chiodo, Michael V.; Alperovich, Michael; Ahn, Christina Y.; Allen, Robert J.; Choi, Mihye; Karp, Nolan S.; Levine, Jamie P.  

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 1086–1093

Background: Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. Methods: Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. Results: Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). Conclusion: Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors’ technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Dosage-dependent reduction of macular pigment optical density in female breast cancer patients receiving tamoxifen adjuvant therapy



by I-Liang Lim, Angela Voon Pei Loo, Visvaraja Subrayan, Tsung Fei Khang, Mee Hoong See, Adlinda Alip, Nur Aishah Mohd Taib  


The Breast June 2018 Volume 39, Pages 117–122

It is now increasingly common for breast cancer patients to receive adjuvant tamoxifen therapy for a period of up to 10 years. As survival rate increases, managing tamoxifen ocular toxicities is important for patients' quality of life. Macular pigments in photoreceptor cells protect against free radical damage, which can cause macular degeneration. By reducing macular pigment concentration, tamoxifen may increase the risk of macular degeneration. Here, we compared macular pigment optical density (MPOD) and central macular thickness between breast cancer patients on tamoxifen adjuvant therapy (n = 70), and a control group (n = 72).

Prolactin Induced Protein (PIP) is a potential biomarker for early stage and malignant breast cancer



 by Anju Gangadharan, Themba Nyirenda, Kishan Patel, Nydia Jaimes-Delgadillo, Dominique Coletta, Takemi Tanaka, Ayal C. Walland, Zena Jameel, Srinivasa Vedantam, Sittinon Tang, Ciaran Mannion, Grace Y. Lee, Andre Goy, Andrew Pecora, K. Stephen Suh  


The Breast June 2018 Volume 39, Pages 101–109

Breast cancer (BC) is the second leading cause of cancer-related mortality in women. Bioinformatic analysis and expression screening showed that Prolactin Induced Protein (PIP) was differentially expressed in BC. The objective of this investigation was to characterize the expression pattern of PIP, an aspartyl proteinase, in malignant and non-malignant breast tissues.

Incidence of isolated local breast cancer recurrence and contralateral breast cancer: A systematic review



by Inge Spronk, Fran├žois G. Schellevis, Jako S. Burgers, Geertruida H. de Bock, Joke C. Korevaar  

The Breast: June 2018 Volume 39, Pages 70–79

An increasing number of women is surviving breast cancer and due to that at risk of developing an isolated ipsilateral breast tumor recurrence (IBTR) or a contralateral breast cancer (CBC). Patients' main concern is cancer recurrence. Patient counseling on breast cancer recurrence is challenging. In order to provide healthcare professionals and patients more guidance, a systematic literature review of the incidence of isolated IBTR and CBC in women diagnosed with early invasive breast cancer was performed.

The Evolving Presence of Women in Academic Plastic Surgery: A Study of the Past 40 Years



by Plana, Natalie M.; Khouri, Kimberly S.; Motosko, Catherine C.; Stern, Marleigh J.; Anzai, Lavinia; Poudrier, Grace; Massie, Jonathan P.; Diaz-Siso, J. Rodrigo; Flores, Roberto L.; Hazen, Alexes  

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 1304–1310

Background: Among surgical subspecialties, plastic surgery holds the highest percentage of women, and, the female contingent of board-certified plastic surgeons and trainees has grown steadily. However, their academic impact has been underestimated. We present the academic footprint of female plastic surgeons over the past 40 years. Methods: A list of female plastic surgeons currently active at, and retired from, Accreditation Council for Graduate Medical Education–accredited plastic surgery residency programs was compiled. Each surgeon was searched on PubMed to gather their total number of publications, journals, and topics of research after completion of training. Date of publication and 5-year impact factor for each journal were recorded. Publications were organized into 10-year periods (1976 to 1985, 1986 to 1995, 1996 to 2005, and 2006 to 2016). Results: One hundred fifty-five currently active and 80 retired academic female plastic surgeons were identified, who published 2982 articles in 479 peer-reviewed journals. The average 5-year impact factor was 4.093. The number of publications increased with each decade: 37 (1976 to 1985), 218 (1986 to 1995), 472 (1996 to 2005), and 2255 (2006 to 2016). The most commonly published areas were hand/nerve (22 percent), craniofacial (21 percent), and breast (20 percent). Over time, publications in hand/nerve research decreased (76, 60, 38, and 14 percent, respectively); craniofacial-related publications increased (8, 11, 18, and 23 percent, respectively); and publications in breast research increased (0, 8, 9, and 24 percent, respectively). The 2006 to 2016 period yielded the most even distribution of research topics. Conclusion: The academic contribution of female plastic surgeons has substantially increased in number and has become more evenly distributed across subspecialty topics.


A Prospective Comparison of Short-Term Outcomes of Subpectoral and Prepectoral Strattice-Based Immediate Breast Reconstruction



by Baker, Benjamin G.; Irri, Renu; MacCallum, Vivienne; Chattopadhyay, Rahul; Murphy, John; Harvey, James R.  

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 1077–1084 

Background: Prepectoral acellular dermal matrix–assisted immediate implant-based breast reconstruction is gaining popularity, involving complete implant coverage with acellular dermal matrix. The authors aimed to compare pain, patient-reported outcome measures (including implant rippling), and safety of prepectoral and subpectoral Strattice–assisted implant-based breast reconstruction. Methods: Consecutive patients were recruited prospectively, having either therapeutic or risk-reducing mastectomy. Patients scored their pain three times per day for the first 7 postoperative days on a Likert scale, and completed the BREAST-Q reconstruction module 3 months postoperatively. Clinical records and the authors’ prospective complications database were used to compare the early morbidity of the two procedures. Results: Forty patients were recruited into the study. There was no significant difference in pain scores between the prepectoral group (mean, 1.5) and the subpectoral cohort (mean, 1.5; p = 0.45) during the first 7 days. Thirty-one BREAST-Q questionnaires were returned; mean Q scores were similar for both prepectoral and subpectoral (72 and 71, respectively; p = 0.81) groups. Patients reported significantly more visible implant rippling in the prepectoral group than in the subpectoral group (seven of 13 versus two of 17; p = 0.02). There was no significant difference in length of stay or early morbidity, with implant loss being 4.7 percent in the prepectoral group compared with 0 percent in the subpectoral group. Conclusions: Early postoperative pain and quality of life at 3 months are equivalent between groups. Early experience of prepectoral implant placement with complete acellular dermal matrix coverage suggests this is safe and provides good quality of life for patients. Further studies are required to compare short- and long-term outcomes with the current standard forms of reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Happy and Unhappy Patients: A Quantitative Analysis of Online Plastic Surgeon Reviews for Breast Augmentation


by Dorfman, Robert G.; Purnell, Chad; Qiu, Cecil; Ellis, Marco F.; Basu, C. Bob; Kim, John Y. S.  

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 663e–673e

Background: Online reviews have become modern versions of the word-of-mouth recommendation, and prospective patients are increasingly consulting them before making decisions about their surgical care. The authors’ objectives were to (1) identify trends in the use of online reviews, and (2) important reasons for patient satisfaction and dissatisfaction with aesthetic surgery. The authors selected breast augmentation as the primary procedure of interest. Methods: Reviews of the top 10 to 20 most reviewed plastic surgeons in each of six large metropolitan areas were obtained from Google, Yelp, and RealSelf. Reviews were assessed for predefined dimensions of satisfaction and dissatisfaction. Results: A total of 1077 breast augmentation reviews were obtained. Ratings were distributed bimodally, with peaks at five stars and one star. The majority of reviews were positive (87.5 percent). Relative popularity of Google versus Yelp varied across geographic regions, and average rating varied by platform. Between 2011 and 2016, the number of online reviews for breast augmentation grew at an average rate of 42.6 percent per year. Aesthetic outcome was the most commonly cited dimension (69.8 percent of reviews), whereas cost was mentioned in only 7.8 percent of reviews. A substantial minority of negative Yelp (37 percent) and Google (9.4 percent) reviews were written by patients who did not actually undergo surgery. Free-text analysis of heterogeneous reviews (containing positive and negative attributes) classified dimensions as critical, redeemable, or protective. Conclusion: As the influence of online review platforms continues to grow, understanding drivers of positive and negative reviews may help surgeons improve patient satisfaction.

The Cost of Contralateral Prophylactic Mastectomy in Women with Unilateral Breast Cancer



by Billig, Jessica I.; Duncan, Anthony; Zhong, Lin; Aliu, Oluseyi; Sears, Erika D.; Chung, Kevin C.; Momoh, Adeyiza O.  

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 1094–1102


Background: Contralateral prophylactic mastectomy may be unnecessary from an oncologic perspective; therefore, the debate persists about the value of contralateral prophylactic mastectomy in women with early-stage unilateral breast cancer. Given finite health care resources, this study aims to evaluate the cost of contralateral prophylactic mastectomy and breast reconstruction. Methods: Women with unilateral breast cancer undergoing either unilateral mastectomy or unilateral mastectomy with contralateral prophylactic mastectomy and immediate breast reconstruction were selected from the Truven MarketScan databases between 2009 and 2013. Demographic and treatment data were recorded, and over an 18-month follow-up period, the treatment cost was tallied. A log-transformed linear model was used to compare cost between the groups. Results: A total of 2343 women were identified who met our inclusion criteria, with 1295 undergoing unilateral mastectomy and 1048 undergoing contralateral prophylactic mastectomy. Complication rates within 18 months were similar for women undergoing unilateral mastectomy and contralateral prophylactic mastectomy (39 percent versus 42 percent; p = 0.17). Management with unilateral mastectomy with reconstruction required an adjusted cumulative mean cost of $33,557. Contralateral prophylactic mastectomy with reconstruction was an additional $11,872 in expenditure (p < 0.001). The cost of initial procedures (mean difference, $6467) and secondary procedures (mean difference, $2455) were the greatest contributors to cost. Conclusions: In women with unilateral breast cancer, contralateral prophylactic mastectomy with reconstruction is more costly. The increased monetary cost of contralateral prophylactic mastectomy may be offset by improved quality of life. However, this financial reality is an important consideration when ongoing efforts toward reimbursement reform may not pay for contralateral prophylactic mastectomy if outcomes data are not presented to justify this procedure.

[News] Sarcopenia and adiposity linked to overall survival



The Lancet Oncology by Elizabeth Gourd Published: 12 April 2018

Patients with non-metastatic breast cancer who have sarcopenia or high total adipose tissue at diagnosis might have an increased risk of mortality, a new study suggests.

[News] No impact of English national cancer policies on survival




[News] No impact of English national cancer policies on survival

The Lancet Oncology by Talha Khan Burki  Published: 22 March 2018

A new study has concluded that the 2000 NHS Cancer Plan and subsequent national cancer policy strategies did not reduce socio-economic inequalities in cancer survival or improve cancer survival overall in England.