Impact of selective use of breast MRI on surgical decision-making in women with newly diagnosed operable breast cancer

Impact of selective use of breast MRI on surgical decision-making in women with newly diagnosed operable breast cancer
Brennan, Meagan E. et al.

The Breast , Volume 32 , 135 - 143

This study evaluated the impact of breast MRI on surgical planning in selected cases of breast malignancy (invasive cancer or DCIS). MRI was used when there was ambiguity on clinical and/or conventional imaging assessment.

An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation

An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation
Barnea, Y et al
Plastic & Reconstructive Surgery:February 2017 - Volume 139 - Issue 2 - p 348e–357e

Background: Patients with a small breast volume and a relative large lumpectomy volume are at risk of developing severe breast deformity and asymmetry following breast conservation, presenting a unique surgical challenge. Methods: A series of patients undergoing immediate reconstruction by means of an oncoplastic breast augmentation technique following breast conservation are described. The technique includes local tissue rearrangement and bilateral subpectoral breast augmentation with implants of different sizes and shapes, immediately after lumpectomy for a malignant tumor. Results: Twenty-one consecutive patients underwent the oncoplastic breast augmentation technique (mean follow-up, 23 months; range, 12 to 48 months). Three patients (14.3 percent) had tumor-positive surgical margins. Postoperative complications included grade III/IV capsular contracture in five patients (23.8 percent) and breast infection in two patients (10 percent). All patients received postoperative radiation therapy. The cosmetic outcome was evaluated at least 6 months after radiation therapy, and it was favorable according to the reported high patient satisfaction (81 percent) and independent observers’ evaluation scores (76 percent). Conclusions: The oncoplastic breast augmentation technique described in this article is an acceptable option in small-breasted patients with a relatively large lumpectomy volume who elect to undergo breast conservation. This technique allows conservation of the affected breast and minimizes potential breast deformation and asymmetry following radiation therapy.

The Evolution of Surgical Simulation: The Current State and Future Avenues for Plastic Surgery Education

The Evolution of Surgical Simulation: The Current State and Future Avenues for Plastic Surgery Education
Kazan, R et al
Plastic & Reconstructive Surgery:February 2017 - Volume 139 - Issue 2 - p 533e–543e

Summary: Alongside the ongoing evolution of surgical training toward a competency-based paradigm has come the need to reevaluate the role of surgical simulation in residency. Simulators offer the ability for trainees to acquire specific skills and for educators to objectively assess the progressive development of these skills. In this article, the authors discuss the historical evolution of surgical simulation, with a particular focus on its past and present role in plastic surgery education. The authors also discuss the future steps required to further advance plastic surgery simulation in an effort to continue to train highly competent plastic surgery graduates.

Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study

Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study
Metcalfe, K A.et al
Plastic & Reconstructive Surgery: February 2017 - Volume 139 - Issue 2 - p 267–275

Background: Delayed breast reconstruction is an option for women who have undergone mastectomy; however, uptake is low. The purpose of this study was to identify premastectomy and postmastectomy demographic, clinical, and psychosocial predictors of uptake of delayed breast reconstruction in the long-term survivorship period. 
Methods: This was a prospective longitudinal survey study of mastectomy patients in which a repeated measures design was used to evaluate uptake of delayed breast reconstruction. Demographic, clinical, and psychosocial variables were collected before mastectomy and 1 year after mastectomy. Information regarding uptake of delayed breast reconstruction was collected at approximately 6 years after mastectomy. A predictive model was designed using a multivariate logistic regression model and Akiake information criterion stepwise algorithm. 
Results: Ninety-six mastectomy patients were followed from before mastectomy to 75.2 months after mastectomy, and 35 women (36.5 percent) underwent delayed breast reconstruction. Women who elected for delayed breast reconstruction experienced worsening of body concerns from before mastectomy to 1 year after mastectomy, compared with women who did not elect to undergo delayed breast reconstruction (p = 0.03). Mean scores for psychological distress were significantly worse both before mastectomy and 1 year after mastectomy in women who went on to undergo delayed breast reconstruction compared with those who did not undergo delayed breast reconstruction (p = 0.034 and p = 0.022, respectively). A predictive model for the uptake of delayed breast reconstruction was developed using demographic, clinical, and psychosocial characteristics. The area under the receiver operating characteristic curve was 85 percent, indicating good precision. Conclusions: Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select delayed breast reconstruction. This may have implications for postreconstruction satisfaction and psychosocial functioning.

An exploration of Australian psychologists' role in assessing women considering risk-reducing or contralateral prophylactic mastectomy

An exploration of Australian psychologists' role in assessing women considering risk-reducing or contralateral prophylactic mastectomy
Braude, Lucy et al.
The Breast , Volume 32 , 105 - 111

Given increasing rates of risk-reducing mastectomies (RRM) and contralateral prophylactic mastectomies (CPM), and the potentially significant psychological sequelae of this irreversible procedure, health professionals (HPs) regularly refer patients to psychologists for pre-operative assessment and support. This is the first study to provide qualitative insights from HPs into the role of psychologists who are working with women considering RRM or CPM.

Evidence-Based Medicine: Autologous Breast Reconstruction

Evidence-Based Medicine: Autologous Breast Reconstruction
Macadam, SA et al
Plastic & Reconstructive Surgery:January 2017 - Volume 139 - Issue 1 - p 204e–229e

Learning Objectives: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. Summary: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey

Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey

The Breast: April 2017Volume 32, Pages 60–65
Coroneos CJ et al

The purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication.

Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: Comparison between immunohistochemical subtypes

Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: Comparison between immunohistochemical subtypes
The Breast: April 2017Volume 32, Pages 37–43
Barrou J et al

Even if neoadjuvant chemotherapy (NACT) and oncoplastic techniques have increased the breast conserving surgery rate, mastectomy is still a standard for multifocal or extensive breast cancers (BC). In the prospect of increasing breast reconstruction, an alternative therapeutic protocol was developed combining NACT with neoadjuvant radiation therapy (NART), followed by mastectomy with immediate breast reconstruction (IBR). The oncological safety of this therapeutic plan still needs further exploration.

Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes

Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes
The Breast: April 2017Volume 32, Pages 7–12
Ilonzo N et al

The landscape of breast reconstruction has changed significantly. This study assesses trends in type of reconstruction performed after mastectomy and impact on immediate postoperative complications.

Reducing implant loss rates in immediate breast reconstructions

Reducing implant loss rates in immediate breast reconstructions
The Breast: February 2017Volume 31, Pages 208–213
Darragh L et al

UK best practice guidelines for oncoplastic breast reconstruction were published in 2012. Implant-based reconstruction quality indicator (QI) targets for readmission, return to theatre and implant loss rates were set at 5% by 3 months, along with guidance to achieve these targets. The aims of this study were to quantify complication rates following implant-based reconstruction before and after the implementation of the guidelines. A retrospective audit of 86 patients with 106 implants in the 12 months to June 2013 was performed, C1.

Over surgery in breast cancer

Over surgery in breast cancer

The Breast: February 2017 Volume 31, Pages 284–289
MacNeill F


Breast surgery remains the original and most effective ‘targeted’ therapy: excision of early cancer is curative and for more advanced disease surgery improves local disease control. However in well intentioned pursuit of cure and local disease control, some cancers are over-treated resulting in major physical and emotional morbidity.Less breast surgery is safe, as evidenced by steady reductions in mortality and local recurrence; earlier diagnosis and widespread use of systemic therapies and radiotherapy have allowed more conservative surgery.

Mastotrainer new version: realistic simulator for training in breast surgery

Mastotrainer new version: realistic simulator for training in breast surgery

Zucca-Matthes, G,Lebovic G,  Lyra M
The Breast February 2017 Volume 31, Pages 82–84 

The “Mastotrainer” was introduced as a new concept of simulators for use in surgical training. Simulators of this type are critical as the use of cadavers is limited or prohibited in some countries. The Mastotrainer has proved very useful in training various surgical techniques, with the first version of the simulator being focused on breast augmentation and reconstruction following mastectomy.This current project explores use of a new version of the surgical simulator that can facilitate a broader spectrum of procedures in the training of breast surgeons as well as plastic and reconstructive surgeons in order to achieve better outcomes.

Fully Awake Breast Reduction

Fully Awake Breast Reduction

Filson, S A. Yarhi, D. Ramon, Y.

Plastic & Reconstructive Surgery November 2016 - Volume 138 - - Issue 5 - p 978–983

Summary: The authors present 25 cases and an in-depth 4-minute video of fully awake aesthetic breast reduction, which was made possible by thoracic epidural anesthesia. There are obvious and important advantages to this technique. Not only does this allow for intraoperative patient cooperation (i.e., patient self-positioning and opinion for comparison of breasts), meaning a shorter and more efficient intraoperative time, there also is a reduction in postoperative pain, complications, recovery, and discharge times. The authors have also enjoyed great success and no complications with this technique in over 150 awake abdominoplasty/total body lift patients. The authors feel that the elimination of the need for general anesthesia by thoracic epidural sensorial–only anesthesia is a highly effective and efficient technique, with very few disadvantages/complications, providing advantages to both patients and surgeons.

Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: Algorithmic Approach to Maximize Efficiency and Safety

Techniques and Perforator Selection in Single, Dominant DIEP Flap Breast Reconstruction: 
Algorithmic Approach to Maximize Efficiency and Safety

Mohan, AT et al

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 790e–803e

Background: Perforator selection is critical to deep inferior epigastric perforator (DIEP) flap harvest. Commitment to a single perforator has the potential benefit of a simpler dissection, but may increase fat necrosis or perfusion-related complications compared with multiple perforator harvest. 
Methods: A 3-year retrospective study was carried out of all patients who underwent DIEP flap breast reconstruction performed by the senior author (M.S.-C). Data were collected on patient demographics and surgical outcomes.
Results: One hundred eighty-three flaps were performed (105 patients) over 3 years. One hundred fifty-six bilateral (78 patients) and 24 unilateral flaps were included in the final study. Mean age was 47.8 ± 8.4 years and mean body mass index was 29.1 ± 5.3 kg/m2. Seventy-five percent of flaps were based on single dominant perforators. Single perforators were used in 33.3 percent of flaps weighing over 1000 g, 80 and 74 percent of flaps weighing 500 to 1000 g and less than 500 g, respectively (p = 0.01). There were no differences in overall complications between single- versus multiple-perforator DIEP flaps. Neither body mass index nor flap weight posed additional risk to overall complications. Conversion to a muscle-sparing flap was 9.4 percent. 
Conclusions: The authors present an algorithm for perforator selection, stepwise approach to flap harvest, and considerations for intraoperative decision-making in DIEP flap reconstruction. Single–dominant perforator flaps can be safely performed, but inclusion of the largest perforator is critical to flap perfusion. Additional perforators must be weighed against the associated tradeoff with donor-site morbidity. The threshold for conversion to a muscle-sparing flap is reduced with increased clinical experience.

Surgeon-Controlled Study and Meta-Analysis Comparing FlexHD and AlloDerm in Immediate Breast Reconstruction Outcomes

Surgeon-Controlled Study and Meta-Analysis Comparing FlexHD and AlloDerm in Immediate Breast Reconstruction Outcomes

Sobti N, Liao E C

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 959–967

Background: The use of acellular dermal matrix has facilitated immediate prosthesis-based breast reconstruction. However, few studies directly compare surgical outcomes following acellular dermal matrix–based reconstruction with two of the most commonly available materials, AlloDerm and FlexHD. Those studies that are available often do not adequately control for the surgeon as a variable. The authors hypothesize that complication rates will not differ significantly between AlloDerm and FlexHD when practice and surgeon variables are properly controlled. Methods: Retrospective review was conducted to identify consecutive implant-based reconstruction procedures performed at a tertiary academic medical institution by a single plastic surgeon over 6 years. Univariate and binomial regression analyses were conducted to compare patient characteristics and clinical endpoints across acellular dermal matrix groups (AlloDerm/AlloDerm ready-to-use versus FlexHD Pliable/Perforated). Results: Of the 233 patients that underwent matrix-based breast reconstruction, 11 (4.7 percent) developed surgical-site infection. The infection rate was not statistically different between patients who received FlexHD [n = 5 (5.0 percent)] versus AlloDerm [n = 6 (4.6 percent)] on either univariate (p = 0.89) or binomial regression analysis (p = 0.56). Likewise, there were no statistical differences in rates of seroma, hematoma, explantation, or delayed wound healing. Conclusions: Clinical endpoints of interest were all equivalent between acellular dermal matrix types. This study uniquely reports a single-surgeon case series comparing outcomes between different acellular dermal matrix types. Instead of focusing on acellular dermal matrix as a predictor of outcome, other patient and surgeon factors should be addressed to improve results and innovate better alternatives.

The Profunda Artery Perforator Flap Experience for Breast Reconstruction

The Profunda Artery Perforator Flap Experience for Breast Reconstruction

Allen, R J et al

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 968–975

Background: The profunda artery perforator flap was first introduced for breast reconstruction in 2010. In this article, the authors analyze the results of all profunda artery perforator flaps performed by their group to date. Methods: A retrospective review was completed of consecutive profunda artery perforator flaps performed by the senior author (R.J.A.) from 2010 to 2014. Patient demographics, indications, operative techniques, flap specifics, complications, and number of operations were recorded. Results: Ninety-six patients have undergone 164 profunda artery perforator flap operations for breast reconstruction since 2010. Reconstructions were performed following breast cancer management (59.5 percent), following prophylactic mastectomy for cancer risk reduction (35.7 percent), and for congenital breast deformity (4.8 percent). The average age of the patients was 48 years (range, 24 to 64 years) and their average body mass index was 22.5 kg/m2. Average flap weight was 367.4 g and average pedicle length was found to be 10.2 cm. The success rate of the profunda artery perforator flap was greater than 99 percent, with a 3 percent take-back rate and only one flap loss recorded. Complications included hematoma (1.9 percent), seroma (6 percent), fat necrosis (7 percent), and donor-site infection (1.9 percent). Conclusions: The profunda artery perforator flap is an excellent option for breast reconstruction. Advantages include a reliable blood supply, long pedicle, thick donor tissue, and a favorable donor site. Currently, the profunda artery perforator flap is second only to the deep inferior epigastric artery perforator among flaps used by the authors for breast reconstruction. 

Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study

Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study

Toesca A et al

The Breast February 2017 Volume 31, Pages 51–56 

We previously devised and reported on an innovative surgical technique of robotic nipple-sparing mastectomy and immediate robotic breast reconstruction. Here we describe the outcome of the first 29 such consecutive procedures performed on breast cancer patients to assess feasibility, reproducibility and safety.

Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

Adams, WP. Mckee, D

Plastic & Reconstructive Surgery November 2016 - Volume 138 - Issue 5 - p 987–994

Background: For primary breast augmentation, several implant selection systems have been described to guide the surgeon with choosing from a variety of manufactured implant dimensions and properties. Controversy exists regarding the most efficacious method of selecting an appropriate implant size that best matches the patient’s breast. 
Methods: The goal of this systematic review was to provide a comprehensive list of documented implant size selection systems, and to critically evaluate them. Implant size selection systems were grouped into categories based on selection principles. Articles were evaluated based on reported outcome measures and methodologic quality. 
Results: Thirty-three implant size selection systems were included in the final analysis. Only 12 percent of articles (four of 33) reported clinical outcomes that could be compared to accepted literature values or industry standards. Articles that described tissue-based planning systems, which use clinical guidelines to determine the optimal patient-specific implant dimensions, were of highest methodologic quality using the Methodological Index for Non-Randomised Studies scale, when compared to systems that used breast “dimensional” analyses that stress tissues to the desire of the patient and/or surgeon, and compared to systems that did not use breast measurement (means ± SD, 6.0 ± 1.4, 1.4 ± 2.3, and 0.0 ± 0.0, respectively). 
Conclusions: There is some evidence to support tissue-based planning as a superior approach to implant size selection planning; studies that used tissue-based planning reported lower reoperation rates compared with industry standards and accepted literature values. The authors offer several suggestions on how to improve the methodologic quality of future studies describing new implant selection systems.

Contemporary social media engagement by breast surgeons

Contemporary social media engagement by breast surgeons

Ekatah GE et al

The Breast December 2016 Volume 30, Pages 172–174

There continues to be a steady rise in the use of social media among healthcare professionals. We present an overview of social media use among breast surgeons within the United Kingdom including demographic variations and some of the factors that underpin these trends. The benefits and drawbacks of open social media platforms are also considered.

Negative-Pressure Wound Therapy: A Comprehensive Review of the Evidence

Negative-Pressure Wound Therapy: A Comprehensive Review of the Evidence


Anghel, EL, Kim, PJ.

Plastic & Reconstructive Surgery September 2016 - Volume 138 - Issue 3S - p 129S–137S

Background: Negative-pressure wound therapy (NPWT) and its variations are an established adjunctive modality for the treatment of wounds. Since its introduction, there have been an increasing number of publications with periods of rapid increases in the number of publications after innovations to the technology. Its application in different wound types and varying clinical scenarios has also contributed to the growing number of publications. 
Methods: A comprehensive literature review (1998–2016) was performed using key words most relevant to NPWT using PubMed/Medline and OVID. Eligibility criteria included higher level evidence studies. 
Results: One thousand three hundred and forty-seven publications were identified. A total of 26 publications are included in this review: 16 comparing NPWT with standard wound dressing, 6 comparing variations of NPWT, and 4 for NPWT with instillation. The level of evidence, wound type studied, reported outcomes and impact, and key findings are tabulated and discussed. 
Conclusions: The number of publications has grown significantly since the inception of NPWT. In part, this reflects the variations of NPWT that have developed. However, a greater number of robust, randomized, prospective studies are needed to support its wide spread use.