[Review] Statistical analysis of patient-reported outcome data in randomised controlled trials of locally advanced and metastatic breast cancer: a systematic review

The Lancet Oncology: Review: Volume 19, issue 9, PE459-PE469, September 01, 2018

Although patient-reported outcomes (PROs), such as health-related quality of life, are important endpoints in randomised controlled trials (RCTs), there is little consensus about the analysis, interpretation, and reporting of these data. We did a systematic review to assess the variability, quality, and standards of PRO data analyses in advanced breast cancer RCTs. We searched PubMed for English language articles published in peer-reviewed journals between Jan 1, 2001, and Oct 30, 2017. Eligible articles were those that reported PRO results from RCTs of adult patients with advanced breast cancer receiving anti-cancer treatments with reported sample sizes of at least 50 patients—66 RCTs met the selection criteria.

[News] New triple-negative breast cancer risk genes identified

[News] New triple-negative breast cancer risk genes identified

by Elizabeth Gourd

The Lancet Oncology : News: Volume 19, issue 9 PE445, September 01, 2018

Multigene hereditary cancer panel testing could be used to identify women with an elevated risk of triple-negative breast cancer as a result of deleterious mutations in five genes, according to a recent study.

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

Quality of life and patient satisfaction after one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage breast reconstruction (BRIOS): primary outcome of a randomised, controlled trial

by Vera Lidwina Negenborn, Danny Aschwin Young-Afat, Rieky Elise Gustina Dikmans, Jan Maerten Smit, Henri Adolf Hubert Winters, Johan Peter William Don Griot, Johannes Wilhelmus Rembertus Twisk, Pieter Quinten Ruhé, Marcus Antonius Maria Mureau, Oren Lapid, Esther Moerman, Adriaan Anne William Martinus van Turnhout, Mathias Joseph Petrus Franciscus Ritt, Mark-Bram Bouman, Margriet Gezina Mullender

The Lancet Oncology: Volume 19, issue 9, P1205-1214, September 01, 2018

Taken together with our previously published findings, one-stage IBBR with ADM does not yield superior results in terms of patient-reported QOL compared with two-stage IBBR. Risks for adverse outcomes were significantly higher in the one-stage ADM group. Use of ADM for one-stage IBBM should be considered on a case-by-case basis.

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy

By O’Connell, Rachel L.; Di Micco, Rosa; Khabra, Komel; Kirby, Anna M.; Harris, Paul A.; James, Stuart E.; Power, Kieran; Ramsey, Kelvin W. D.; Rusby, Jennifer E.  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 594–605

Background: The authors investigated aesthetic outcome and patient satisfaction in women who have undergone deep inferior epigastric artery perforator (DIEP) flap reconstruction in the setting of postmastectomy radiotherapy. Patients who underwent DIEP flap reconstruction without postmastectomy radiotherapy were the control group.

Methods: Participants who had undergone DIEP flap reconstruction between September 1, 2009, and September 1, 2014, were recruited, answered the BREAST-Q, and underwent three-dimensional surface-imaging. A panel assessed the aesthetic outcome by reviewing these images. Results: One hundred sixty-seven women participated. Eighty women (48 percent) underwent immediate DIEP flap reconstruction and no postmastectomy radiotherapy; 28 (17 percent) underwent immediate DIEP flap reconstruction with postmastectomy radiotherapy; 38 (23 percent) underwent simple mastectomy, postmastectomy radiotherapy, and DIEP flap reconstruction; and 21 (13 percent) underwent mastectomy with temporizing implant, postmastectomy radiotherapy, and DIEP flap reconstruction. Median satisfaction scores were significantly different among the groups (p < 0.05). Post hoc comparison demonstrated that women who had an immediate DIEP flap reconstruction were significantly less satisfied if they had postmastectomy radiotherapy. In women requiring radiotherapy, those undergoing delayed reconstruction after a simple mastectomy were most satisfied, but there was no significant difference between the immediate DIEP flap and temporizing implant groups. Median panel scores differed among groups, being significantly higher if the immediate reconstruction was not subjected to radiotherapy. There was no significant difference in panel assessment among the three groups of women who had received radiotherapy.

Conclusions: Patients who avoid having their immediate DIEP flap reconstruction irradiated are more satisfied and have better aesthetic outcome than those who undergo postmastectomy radiotherapy. In women requiring radiotherapy and who wish to have an immediate or “delayed-immediate” reconstruction, there were no significant differences in panel or patient satisfaction. Therefore, immediate DIEP flap reconstruction or mastectomy with temporizing implant then DIEP flap surgery are acceptable treatment pathways in the context of post-mastectomy radiotherapy.

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

by Turin, Sergey Y.; Li, Daniel D.; Vaca, Elbert E.; Fine, Neil  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 264e–270e

Background: Mastectomy flap necrosis remains a challenging complication in immediate tissue expander breast reconstruction. Nitroglycerin ointment has been shown to reduce the incidence of mastectomy flap necrosis in a randomized controlled study, using 45 g per breast and treating one side only in bilateral cases. This study was conducted to determine the efficacy of 15 g of nitroglycerin ointment per breast, therefore permitting application to both breasts in cases of bilateral mastectomy. Methods: A retrospective cohort study of patients undergoing immediate tissue expander breast reconstruction performed by a single reconstructive surgeon was conducted. The intervention cohort consisted of all patients between June 10, 2015, and June 9, 2016 (94 patients, 158 breasts), where 15 g of nitroglycerin ointment was routinely applied per breast. The control cohort consisted of all patients from June 10, 2014, to June 9, 2015 (107 patients, 170 breasts), where nitroglycerin was not applied. All complications were tracked, including minor wound healing problems. Results: There was an overall 22 percent decreased incidence of mastectomy flap necrosis in the nitroglycerin ointment cohort (47.5 percent versus 60.6 percent; p = 0.002), with a 44 percent reduction in full-thickness mastectomy flap necrosis that trended toward statistical significance (9.5 percent versus 16.5 percent; p = 0.06). On multivariate analysis, nitroglycerin application was independently associated with a decrease in mastectomy flap necrosis or need for mastectomy flap débridement. There was no significant difference in the incidence of postoperative hypotension (3.8 percent versus 2.9 percent) or headache among cohorts. Conclusion: Topical nitroglycerin ointment application to mastectomy skin flaps at 15 g per breast is a cost-effective means of decreasing the incidence of mastectomy flap necrosis in unilateral and bilateral immediate tissue expander breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens

Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens

by Arlene Chan, Astrid Bauwens, Sally Pontre, Sally Jackson, Frances McGlone, Tracie Ernenwein, Jun Chih, Christopher Reid  

The Breast: October 2018 Volume 41, Pages 127–132

Hair loss as a result of chemotherapy for early breast cancer (EBC) is a frequent and distressing side effect. Minimising hair loss may improve mood and body image. Our aim was to determine scalp cooling (SC) efficacy in EBC patients receiving contemporary chemotherapy regimen, to inform future patients choice to use SC or not.

Evidence-Based Interventions: Consultation Document [PDF] (see page 43-47)

Evidence-BasedInterventions: Consultation Document [PDF] (see page 43-47)

Source:  NHS England - 10 July 2018 - Publisher: NHS England

NHS England is seeking views on the proposed policy for reducing the delivery of clinically ineffective interventions. Consultation ends on 28 September 2018.

Complementary therapies, relaxation and wellbeing (BCC55) [PDF]

Complementary therapies,relaxation and wellbeing (BCC55) [PDF]

Source:  Breast Cancer Care - 26 June 2018 (via NICE)

This booklet is about relaxation and wellbeing during and after breast cancer treatment. It looks at complementary therapies such as acupuncture, Reiki and massage. It also describes some popular relaxation techniques, including meditation and mindfulness, and has information on yoga, Tai Chi and Chi Gung. We discuss why people might use these complementary therapies and relaxation techniques after a diagnosis of breast cancer, and what you may need to think about before trying them. We also explain what herbal medicines and homeopathy are.

*Please let me know whether resources like this are of any use to you. If so, I'll just do a NICE search in relation to breast surgery each month to accompany the research articles. 

Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men

Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men

1 Plastic and Reconstructive Surgery   by Frey, Jordan D.; Yu, Jessie Z.; Poudrier, Grace; Motosko, Catherine C.; Saia, Whitney V.; Wilson, Stelios C.; Hazen, Alexes  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 331–336

Background: A primary goal in chest wall reconstruction (“top surgery”) for trans men is achieving a symmetric, aesthetically pleasing position of the reconstructed male nipple-areola complex. Methods: The senior author’s (A.H.) technique for component nipple-areola complex creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March of 2015 to October of 2016. Results: The average patient age was 30.64 years, and the average body mass index was 28.54 kg/m2. Eighty-two percent of the sample received preoperative testosterone therapy, and average operative time was 2 hours 59 minutes. Average overall mastectomy specimen weight was 627.80 g, average length of hospital stay was 0.96 days, and average follow-up duration was 19.02 months. Complications occurred in five patients (10 percent), including seroma (4 percent), cellulitis (2 percent), hematoma (2 percent), and suture granuloma (2 percent). Only five patients (10 percent) underwent postoperative revision to adjust nipple-areola complex size, projection, or symmetry. Twenty-eight patients (56 percent) underwent secondary revisions, including scar revisions (56 percent), liposuction (12 percent), and fat grafting (2 percent). Conclusion: The use of a modified nipple flap and free areola graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male nipple-areola complex in a safe and effective manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction

Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction

by Cohen, Oriana; Lam, Gretl; Choi, Mihye; Ceradini, Daniel; Karp, Nolan  

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 299–305

Background: Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, the authors determine how postoperative complications impact chemotherapy timing, and identify factors associated with greater risk for delays. Methods: Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of postoperative complications and time to chemotherapy. Results: A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86 percent) reconstructions did not experience postoperative complications, and 34 (13.9 percent) did. Patients who experienced postoperative complications had an older mean age (53.6 years versus 48.1 years; p = 0.002) and higher rates of diabetes (23.5 percent versus 3.8 percent; p < 0.001). The complication group had delays in initiation of chemotherapy (56 versus 45 days; p = 0.017). Patients who initiated chemotherapy more than 48.5 days after reconstruction were of older mean age (55.9 years versus 50.7 years; p = 0.074) and had increased rates of diabetes (36.8 percent versus 6.7 percent; p = 0.053) and immediate autologous reconstruction (31.6 percent versus 0 percent; p = 0.027). A predictive model determined that patients with at least one of these three risk factors have a 74 percent chance of experiencing prolonged times to chemotherapy initiation. Conclusions: Risk factors for delayed chemotherapy in the context of postoperative complications are age older than 51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

[Perspectives] Breast cancer in a Renaissance Book of the Dead

[Perspectives] Breast cancer in a Renaissance Book of the Dead

The Lancet Oncology by Emma Nicholls  

PERSPECTIVES|HISTORY OF MEDICINE| VOLUME 19, ISSUE 8, P1023-1024, AUGUST 01, 2018

Walking around galleries of great Renaissance art, many visitors have found themselves staring in puzzlement at female nudes who seem to have oddly shaped breasts. In recent years, a number of medical specialists, working in partnership with art historians, have argued that we should be less quick to dismiss these apparent malformations as the result of artistic ineptitude. Instead, they argue that to the trained eye, these bulges, depressions, and retractions unmistakably signal the willingness of Renaissance artists to depict women with breast pathologies.

[News] Mammography deficiencies: the result of poor positioning

[News] Mammography deficiencies: the result of poor positioning

The Lancet Oncology by Elizabeth Gourd  

NEWS| VOLUME 19, ISSUE 8, PE385, AUGUST 01, 2018

Poor patient positioning is the leading cause of clinical image deficiencies and accreditation failures in mammography, according to a recent investigation.

Comparing Therapeutic versus Prophylactic Nipple-Sparing Mastectomy: Does Indication Inform Oncologic and Reconstructive Outcomes?

Comparing Therapeutic versus Prophylactic Nipple-Sparing Mastectomy: Does Indication Inform Oncologic and Reconstructive Outcomes?

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

Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 306–315

Background: Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. Methods: Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. Results: A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). Conclusions: Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases

The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases

by Opsomer, Dries; Stillaert, Filip; Blondeel, Phillip; Van Landuyt, Koenraad  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 1e–8e

Background: The lumbar artery perforator flap is an alternative flap in breast reconstruction for those patients who are not eligible for a deep inferior epigastric artery perforator (DIEAP) flap. Shaping of this flap is easier compared with other flaps because of the quality of the lumbar fat and the gluteal extension. Methods: Between October of 2010 and June of 2017, a total of 100 lumbar artery perforator free flap breast reconstructions were performed in 72 patients. Patient demographics, indications, flap specifics, and complications were reviewed retrospectively. Results: Twenty-eight bilateral and 44 unilateral breast reconstructions with a lumbar artery perforator flap were performed. Mean patient age was 48 years, and the average body mass index was 23.11 kg/m2. The authors report 43 preventive mastectomies for elevated cancer risk with subsequent immediate reconstruction, 34 secondary reconstructions, and 14 tertiary reconstructions. Mean operative time was 7 hours 4 minutes, including the mastectomy in primary cases. Mean flap weight was 499 g (range, 77 to 1216 g) and mean follow-up time was 30 months. The revision rate was 22 percent and nine flaps were lost. Conclusions: The lumbar artery perforator flap is a valuable alternative to the DIEAP flap in breast reconstructive surgery. It is an excellent flap for BRCA-positive patients who are typically young and have limited excess tissue at the conventional donor sites. Despite higher revision rates compared with the DIEAP flap, the lumbar flap is superior in mimicking the shape and feel of native breast tissue. Scarring at the donor site remains a sore point but can be easily treated and used to an advantage to contour the flanks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Implications of Barbed Sutures on Scar Aesthetics: A Systematic Review

The Implications of Barbed Sutures on Scar Aesthetics: ASystematic Review

Authors: Motosko, Catherine C., B.S.; Zakhem, George A., B.S.; Saadeh, Pierre B., M.D.; Hazen, Alexes, M.D.

Journal: Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 337–343

Background: Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast operations, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regard to scarring.

Methods: A systematic review of the PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July of 2017 using the search terms “barbed suture” combined with “scar” or “wound.” Studies were included if they were prospective, evaluator-blind, randomized, controlled trials; closed the dermal layer of incisions using barbed sutures; and included an evaluator-blind aesthetic assessment of scarring.

Results: Six prospective, randomized, controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the six controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and one study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in four of the five studies that timed incision closure. Similar complication rates were observed in all evaluated studies.

Conclusion: Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.

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

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

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

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”

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

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.