Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging

 Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging

 by Haddock, Nicholas T.; Dumestre, Danielle O.; Teotia, Sumeet S. 

Plastic and Reconstructive Surgery: October 2020 - Volume 146 - Issue 4 - p 719-723

Background: In deep inferior epigastric perforator (DIEP) flap breast reconstruction, many surgeons use preoperative imaging for perforator mapping as a method to plan the operation, reduce operative times, and potentially limit morbidity. This study compared operative times for specific portions of DIEP flap harvest with and without preoperative computed tomographic angiography imaging.

Methods: Two patient groups undergoing DIEP flap breast reconstruction were studied prospectively. In the experimental group, the harvesting surgeon was blinded to the preoperative computed tomographic angiography scan; in the control group, the harvesting surgeon assessed the scan preoperatively. Times for initial perforator identification, perforator selection, flap harvest time, and total procedure times were compared. Perforator choice was evaluated. Correlation of perforator choice preoperatively and intraoperatively was also performed.

Results: Times were recorded in 60 DIEP flaps (27 blinded and 33 unblinded). The nonblinded group was more efficient in all categories: time to first perforator identification (28.6 minutes versus 17.8 minutes; p < 0.0001), time to perforator decision-making (23.1 minutes versus 5.6 minutes; p < 0.0001), time to flap harvest (128 minutes versus 80 minutes; p < 0.0001), and total operative time (417 minutes versus 353 minutes; p < 0.001). Perforator location was not different between groups. Blinded intraoperative decisions correlated with preoperative imaging in 74 percent of flaps. More perforators were included in the blinded flaps compared to the nonblinded flaps (2.3 versus 1.4; p < 0.001).

Conclusions: Use of preoperative computed tomographic angiography leads to decreased operative times, specifically with regard to perforator identification and perforator selection. Without preoperative computed tomographic angiography, surgeons included more perforators in the flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

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

 

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

 

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

 

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

 

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

 

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

 

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

 

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

 

Background:

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

Methods:

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

Results:

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

Conclusion:

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

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

 

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

by Anthony B Miller

 

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

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

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

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

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

 

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

 

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

National Institute for Health Research Health Technology Assessment programme.

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

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

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

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

 

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

 

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

 

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

AstraZeneca.

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

 

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

 

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

 

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

 

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

 

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

 

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

 

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

 

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

 

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

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

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

 

Learning Objectives:

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

1. Understand the relevant anatomy involved in breast reduction.

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

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

 

Summary:

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

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

 

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

 

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

 

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

 

Background:

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

 Methods:

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

Results:

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

Conclusions:

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

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

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

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

 

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

 

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

 

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

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

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy

Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy

by Hanson, Summer E.; Kapur, Sahil K.; Garvey, Patrick B.; Hernandez, Mike; Clemens, Mark W.; Hwang, Rosa F.; Dryden, Mark J.; Butler, Charles E.

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 215-225

Background:

Autologous fat grafting is a useful adjunct following breast reconstruction. The impact of autologous fat grafting on oncologic safety and surveillance remains questionable, particularly following breast conservation therapy.

Methods:

The authors performed a retrospective review of patients who underwent delayed fat grafting following breast conservation therapy between 2006 and 2016. A control group of conservatively managed patients without grafting was matched for cancer stage, age, body mass index, and follow-up. Outcomes included locoregional recurrence and oncologic surveillance.

Results:

Seventy-two patients were identified per cohort. There were no differences in median age (50 years versus 51 years; p = 0.87), body mass index (28.2 kg/m2 versus 27.2 kg/m2; p = 0.38), or length of follow-up (61.9 months versus 66.8 months; p = 0.144) between controls and grafted patients, respectively. Overall, four patients in each cohort experienced recurrence (5.6 percent; p = 1.00) with similar cumulative incidence estimates observed (log-rank test, p = 0.534). There were no significant differences in palpable mass (9.7 percent versus 19.4 percent; p = 0.1), fat necrosis (34.7 percent versus 33.3 percent; p = 0.86), calcifications (37.5 percent versus 34.7 percent; p = 0.73), or indication for breast biopsy (15.3 percent versus 22.2 percent; p = 0.23) between breast conservation and breast conservation therapy plus autologous fat grafting cohorts, respectively.

Conclusions:

Overall, the authors found no difference in recurrence rates after breast conservation with or without delayed fat grafting. Furthermore, there were no differences in the rates of fat necrosis, palpable mass, and abnormal radiographic findings. This study represents the longest follow-up to date in in a large matched study of autologous fat grafting with breast conservation therapy demonstrating oncologic safety and no interference with follow-up surveillance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Should we worry about residual disease after mastectomy?

Should we worry about residual disease after mastectomy?

by Orit Kaidar-Person, Thorsten Kühn, Philip Poortmans 

The Lancet Oncology: volume 21, issue 8, p1001-1013. August 01, 2020

Breast cancer is the most frequently diagnosed cancer in women, accounting for 30% of new cancer cases, and leads to the highest proportion (15%) of cancer deaths.1 Surgical resection is the cornerstone of treatment with curative intent for patients with non-metastatic breast cancer, within comprehensive treatment from an integrated multidisciplinary team. The aim of resection is to remove all neoplastic tissue in the breast (both invasive cancer and ductal carcinoma in situ [DCIS]), to reduce the risk of further disease spread, including local and distant recurrence.

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Knowledge gaps in oncoplastic breast surgery (Review)

 Knowledge gaps in oncoplastic breast surgery (Review)

by Walter P Weber, Monica Morrow, Jana de Boniface, Andrea Pusic, Giacomo Montagna, Elisabeth A Kappos, Mathilde Ritter, Martin Haug, Christian Kurzeder, Ramon Saccilotto, Alexandra Schulz, John Benson, Florian Fitzal, Zoltan Matrai, Jane Shaw, Marie-Jeanne Vrancken Peeters, Shelley Potter, Joerg Heil, Oncoplastic Breast Consortium

The Lancet Oncology: volume 21, issue 8 (375-385), August 01, 2020 

The aims of the Oncoplastic Breast Consortium initiative were to identify important knowledge gaps in the field of oncoplastic breast-conserving surgery and nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction, and to recommend appropriate research strategies to address these gaps. A total of 212 surgeons and 26 patient advocates from 55 countries prioritised the 15 most important knowledge gaps from a list of 38 in two electronic Delphi rounds. An interdisciplinary panel of the Oncoplastic Breast Consortium consisting of 63 stakeholders from 20 countries obtained consensus during an in-person meeting to select seven of these 15 knowledge gaps as research priorities.

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Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery

Link to article: Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery

by Djohan, Risal; Scomacao, Isis; Knackstedt, Rebecca; Cakmakoglu, Cagri; Grobmyer, Stephen R. 

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 250-254

Summary:

The concept of sensate autologous breast reconstruction is not novel, and prior literature has focused mainly on sensate abdominally based breast reconstruction. The goal of this article is to present the authors’ results with a novel technique performing sensate implant-based reconstruction. A database was prospectively maintained for patients who underwent implant-based sensate breast reconstruction. The anterior branch of the lateral fourth intercostal is identified and preserved during the mastectomy by the breast surgeon. A processed nerve allograft is used as an interpositional graft connecting the donor nerve to the targeted nipple-areola complex. The sensory recovery process was objectively monitored using a pressure-specified sensory device. Thirteen patients underwent the proposed technique. Eight patients with 15 breasts were monitored for sensory recovery. For sensory measurement, the nipple had a mean threshold of 67.33 ± 34.48 g/nm2. The upper inner (29 ± 26.75 g/nm2) and upper outer (46.82 ± 32.72 g/nm2) nipple-areola complex quadrants demonstrated better scores during the moving test compared with the static test. Mean time between the test and surgery was 4.18 ± 2.3 months, and mean time between the second test and surgery was 10.59 ± 3.57 months. Threshold improvements were documented after the second test for all nipple-areola complex areas evaluated. This is the first study to report on early results obtained after performing sensate implant-based breast reconstruction. More studies are required to determine the long-term outcomes and impact on quality of life and to assess whether patient or breast characteristics impact the success of this procedure.

Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

Link to article: Intravenous Tranexamic Acid in Implant-Based Breast Reconstruction Safely Reduces Hematoma without Thromboembolic Events

by Weissler, Jason M.; Banuelos, Joseph; Jacobson, Steven R.; Manrique, Oscar J.; Nguyen, Minh-Doan T.; Harless, Christin A.; Tran, Nho V.; Martinez-Jorge, Jorys

Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 238-245

Background:

Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction.

Methods:

 A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher’s exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.

Results:

A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma.

Conclusions:

 Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Health-Related Quality of Life after Four Common Surgical Treatment Options for Breast Cancer and the Effect of Complications: A Retrospective Patient-Reported Survey among 1871 Patients

Link to article: Long-Term Health-Related Quality of Life after Four Common Surgical Treatment Options for Breast Cancer and the Effect of Complications: A Retrospective Patient-Reported Survey among 1871 Patients

by Kouwenberg, Casimir A. E.; de Ligt, Kelly M.; Kranenburg, Leonieke W.; Rakhorst, Hinne; de Leeuw, Daniëlle; Siesling, Sabine; Busschbach, Jan J.; Mureau, Marc A. M.

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1-13

Background:

Differences in quality-of-life outcomes after different surgical breast cancer treatment options, including breast reconstruction, are relevant for counseling individual patients in clinical decision-making, and for (societal) evaluations such as cost-effectiveness analyses. However, current literature shows contradictory results, because of use of different patient-reported outcome measures and study designs with limited patient numbers. The authors set out to improve this evidence using patient-reported outcome measures in a large, cross-sectional study for different surgical breast cancer treatment options.

Methods:

Quality of life was assessed through the EQ-5D-5L, European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and BR23, and the BREAST-Q. Patients with different treatments were compared after propensity-weighted adjustment of pretreatment differences. The EQ-5D was used to value the effect of surgical complications.

Results:

A total of 1871 breast cancer patients participated (breast-conserving surgery, n = 615; mastectomy, n = 507; autologous reconstruction, n = 330; and implant-based reconstruction, n = 419). Mastectomy patients reported the lowest EQ-5D score (mastectomy, 0.805, breast-conserving surgery, 0.844; autologous reconstruction, 0.849; and implant-based reconstruction, 0.850) and functioning scores of the C30 questionnaire. On the BREAST-Q, autologous reconstruction patients had higher mean Satisfaction with Outcome, Satisfaction with Breasts, and Sexual Well-being scores than implant-based reconstruction patients. Complications in autologous reconstruction patients resulted in a substantially lower quality of life than in implant-based reconstruction patients.

Conclusions:

This study shows the added value of breast conservation and reconstruction compared with mastectomy; however, differences among breast-conserving surgery, implant-based reconstruction, and autologous breast reconstruction were subtle. Complications resulted in poorer health-related quality of life.

Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

Link to article: Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance

by Hembd, Austin S.; Yan, Jingsheng; Zhu, Hong; Haddock, Nicholas T.; Teotia, Sumeet S.

Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 1e-10e

Background:

This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction.

Methods:

 A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure.

Results:

Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits.

Conclusion:

Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Attachments of the Breast to the Chest Wall: A Dissection Study

Link to article: The Attachments of the Breast to the Chest Wall: A Dissection Study

by Gaskin, Kathryn M.; Peoples, Gregory E.; McGhee, Deirdre E. 

Plastic and Reconstructive Surgery :  July 2020 - Volume 146 - Issue 1 - p 11-22e

Background: 

The anatomical descriptions of the attachments of the female breast to the chest wall vary in their structure, location, and terminology within the published literature.

Methods: 

A dissection study of the attachments of the breast to the chest wall was conducted on 18 female embalmed breasts in the coronal (n = 15) and sagittal planes (n = 3).

Results: 

Perimeter, posterior wall, and horizontal septum attachments were observed. The perimeter along its entire length was attached to the chest wall. Regional and anatomical variation was observed in this structure and location. Sharp dissection was required to remove it from the chest wall, in contrast to the blunt dissection required to remove the posterior wall and horizontal septum attachments.

Conclusions: 

The breast attaches to the chest wall along its entire perimeter, posterior wall, and horizontal septum, with the perimeter functioning as the primary anchor of the breast to the chest wall. The structure of the perimeter attachment is both periosteal and fascial and requires sharp dissection to remove it from the chest wall. The fascial structures of the posterior wall and horizontal septum require blunt dissection only. The structure of the perimeter has regional variation, and its location on the chest wall has anatomical variation. Detailed anatomical descriptions and illustrations are supported by photographic evidence of cadaver dissections in two planes. Clinical and anatomical terminology are linked, with clinical implications for medical anatomy education, breast modeling, and breast surgery.