Mastectomía preservadora de piel con colgajo dermograso desepitelizado (técnica de Spira modificada) y reconstrucción mediante implante directo

IntroductionSpira technique is a type of nipple-sparing mastectomy that allows immediate reconstruction (IBR), ideal for ptosic breasts. Although, controversy persists regarding oncological results in breast cancer. The aim is to analyze complications, cosmetic outcomes, causes of reoperation and oncological results.MethodsRetrospective observational analysis of patients undergone surgery during 2003-2018 in our center. Study population is based on patients with breast carcinoma or undergoing prophylactic mastectomy due to high-risk, in which a skin-sparing mastectomy with a de-epithelialized derma-fat flap (modified Spira technique) and direct to implant reconstruction was performed. Short and long-term complications, sequelae, tumor recurrence and survival rates are analyzed.ResultsA total of 247 mastectomies with immediate reconstruction in 139 patients, 216 bilateral (87.4%) and 31 unilateral (12.5%) were performed. 121 therapeutic (49%) and 126 prophylactic (51%). Median follow-up 81 months. Complications were observed in 16.2%; skin necrosis 5.3% and 5 cases of NAC necrosis (2%). Reoperation rate due to cosmetic sequelae was 17.4% (capsular contracture was the most frequent,11.3%) and a 39.3% of these patients have received RT. Recurrence of 14% (0.8% skin, 3.3% locoregional and 9.9% metastatic), 8 patients died (6.6%). Rates of FSD and OS were 92.6% and 93.3% respectively.ConclusionSpira mastectomy is a safe option and provides good cosmetic and oncologic results as breast cancer treatment and prophylaxis in moderate-large ptosic breasts.     

Mastectomy patterns,but not rates,are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients

BackgroundRecent literature reports that rates of mastectomy are increasing in early breast cancer. However, data from European institutions are limited and revealed conflicting results. We report on 15-year trends of mastectomy, mastectomy plus immediate reconstruction and contralateral prophylactic mastectomy (CPM) at an academic institution.MethodsWe identified women diagnosed with unilateral early breast cancer at stage 0-IIa, with tumour size ≤ 4 cm, between 2002 and 2016. Trends were assessed using the Cochrane–Armitage test. Multivariable logistic regression was used to identify factors associated with receipt of mastectomy plus immediate reconstruction.ResultsA total of 2315 patients were identified. Of them, 65.7% underwent breast conserving surgery (BCS), while 34.3% underwent mastectomy as upfront surgery. Two point four per cent also received CPM. Immediate reconstruction was performed in 36.0% of patients receiving mastectomy. There was no change in trends of mastectomy over the 15 years studied (p = 0.69), as well as in trends of patients undergoing CPM (p = 0.44). In contrast, rates of immediate reconstruction rose significantly over the study period (from 12.2% in 2002 to 62.7% in 2016, p < 0.0001). Women were more likely to receive mastectomy plus immediate reconstruction if they were aged 50 years or younger, or had tumours larger than 2 cm, or had non-invasive carcinoma.ConclusionsOur study suggests that rates of both mastectomy and CPM in early breast cancer are not increasing, while use of immediate reconstruction is on the rise.     

双侧乳房重建118例单中心回顾性研究

目的 探讨双侧乳房重建手术的开展情况和影响因素。方法 对复旦大学附属肿瘤医院2000年1月至2019年12月间接受双侧乳房重建手术的病人资料进行回顾性分析,描述病人人口学、临床病理特征、双侧乳房重建手术规模、手术时机和方式,探讨双侧乳房重建手术方式选择过程中的影响因素。采用t检验、χ2检验以及Fisher检验进行显著性检验;利用单因素及多因素回归分析,对上述影响因素进行统计学检验。结果 2913例病人接受乳腺癌全乳切除术后乳房重建,其中双侧乳房重建病人共118例,占重建总数的4.05%。双侧乳腺癌病人82例,对侧乳房预防性切除的单侧乳腺癌病人31例,15例病人为一侧或双侧延期乳房重建。双侧即刻重建者103例,占87.3%,10例病人行单侧乳房延期重建,5例行双乳延期重建。双侧植入物重建97例（82.2%）,一侧植入物重建另一侧自体重建共9例（7.6%）,其余12例（10.2%）为双侧自体重建。乳房切除动机（治疗性/预防性）、双侧乳房切除时机（同时性/异时性）以及辅助放疗与双侧乳房重建方式选择相关。多因素分析发现,异时性双乳切除病人与术后需要行辅助放疗的病人更倾向于选择一侧或双侧自体重建。同时行双乳切除接受即刻植入物重建时,扩张器-假体两步法占比更高,达76.5%。和单侧乳房重建比较,双侧乳房重建术后非计划再次手术和重建失败的比例差异无统计学意义。结论 当前国内双侧乳房重建的占比虽然较低,但是面临潜在的增长趋势。乳腺癌多学科团队应制订合理的手术适应证,结合病人意愿,选择恰当的手术时机和方式,从而使临床决策更为规范。     

Hypofractionated versus conventional fractionated radiotherapy for breast cancer in patients with reconstructed breast: Toxicity analysis

PurposeThis study investigated whether hypofractionated adjuvant radiotherapy (RT) increased breast-related complication(s) compared to conventional fractionated RT in reconstructed breast cancer patients.MethodsWe conducted a retrospective review including 349 breast cancer patients who underwent immediate breast reconstruction following mastectomy or breast-conserving surgery (BCS) between 2009 and 2018 at two institutions. All patients were treated with adjuvant RT via either a conventional fractionated or hypofractionated regimen. We defined a major breast complication as a breast-related toxic event requiring re-operation or re-hospitalization during the follow-up period after the end of RT.ResultsThe median follow-up was 32.3 months (4.8–118.5 months); 126 patients had conventional fractionated RT, and 223 patients received hypofractionated RT. In patients with mastectomy, there was no significant difference in the occurrence of any or major breast-related complications between the two fractionation regimens. In patients undergoing BCS, incidence of any breast complication showed no difference between two RT groups and no major breast complication was reported as well. Hypofractionated RT did not increase major wound problem (infection and dehiscence) compared to conventional RT. Incidence of major contracture was significantly lower in hypofractionated RT.ConclusionsThere was no significant difference in the occurrence of any or major breast-related complications between the two different fractionation regimens, even in patients with mastectomy. Hypofractionated RT may be used comparable to conventional fractionated RT in terms of breast-related complications in reconstructed breast cancer patients. The prospective randomized trial would be necessary to clarify this issue.     

Bilateral nipple-sparing mastectomy and breast reconstruction in BRCA1 mutation-positive simultaneous bilateral breast cancer: A case study

BackgroundMutation-positive patients who develop unilateral breast cancer require different treatments, such as prophylactic mastectomy of the contralateral breast, from those used for other breast cancer patients. If a mutation is found before surgery, it is necessary to consider a surgical procedure that includes reconstruction. For BRCA mutation-positive patients, a suitable treatment must be selected. In Japan, a test for BRCA mutation has been covered by health insurance since 2020, making it possible to preoperatively test patients who are suspected of being positive. We report a case of simultaneous bilateral breast cancer that was found to be BRCA mutation-positive preoperatively and underwent bilateral subcutaneous mastectomy and breast reconstruction.Case presentationA 57-year-old woman was admitted to our hospital after a breast cancer screening revealed a mass in the left breast. She had a family history of breast cancer, including her sister, aunt, and cousin. She was suspected of being malignant with a mass on both sides of her breast on imaging. She underwent needle biopsy and was diagnosed as having bilateral invasive ductal carcinoma, for which she was placed on preoperative chemotherapy. Due to the strong family history of bilateral breast cancer, the patient was recommended to undergo a BRCA gene-mutation test and she consented. The result was positive for BRCA1 mutation. Although it was judged that bilateral breast-conserving surgery was sufficiently possible, bilateral subcutaneous mastectomy and breast reconstruction were performed based on BRCA mutation-positive status.DiscussionPerforming a preoperative BRCA test may change the surgical procedure.BRCA tests are beneficial to patients, but the timing of the tests is important. Care must be taken not to force the patient.ConclusionsKnowing whether the patient is BRCA mutation-positive is extremely important for selecting surgical procedures and treatment methods. BRCA testing should be recommended for patients who are strongly suspected of being positive, but the decision should be the patient’s. It is therefore necessary to provide accurate information and engage in a dialogue with the patient, but the medical staff should not pressure the patient to have the test.     

Incremental Risk Associated with Contralateral Prophylactic Mastectomy and the Effect on Adjuvant Therapy

Background

Contralateral prophylactic mastectomy (CPM) is expected to add surgical morbidity but this incremental risk has not yet been defined. We sought to quantify the additional risks associated with CPM and determine how these risks influence the time to adjuvant therapy.

Methods

We identified women undergoing mastectomy for unilateral breast cancer and stratified them according to the use of CPM and the presence and laterality of surgical complications. We measured time to adjuvant therapy.

Results

Of 352 patients, 205 (58 %) underwent unilateral mastectomy (UM) and 147 (42 %) underwent bilateral mastectomy (BM) [BM = UM + CPM]. Overall, 94/352 (27 %) women suffered 112 complications (BM: 46/147 [31 %] vs. UM: 48/205 [23 %]; p = 0.11), of which hematoma, skin necrosis, cellulitis, or seroma accounted for 94/112 (84 %) complications. Reoperation was required in 37/352 (10 %) women. Among those undergoing BM, morbidity occurred only in the prophylactic breast in 19/147 (13 %) women and risk did not differ with immediate reconstruction (13/108 [12 %]) or without (6/39 [15 %]). Of these 19 patients, 10 (53 %) required reoperation. Women with any complication had a longer interval to adjuvant therapy when compared with those without (49 days vs. 40 days; p < 0.001). When stratified according to side, complications in the prophylactic breast were not associated with a delay in treatment (UM: 58 days vs. BM: prophylactic side; 41 days vs. BM: cancer side: 50 days; p = 0.73).

Conclusions

CPM confers additional morbidity in one in eight women, of whom half require reoperation. Despite this, in our series CPM did not delay adjuvant therapy. Given the rising incidence of patients seeking CPM, they should be informed of this risk.     

Risk of breast implant removal after one- versus two-stage breast reconstructive surgery

BackgroundTo date, both one- and two-stage techniques are used in immediate ‘implant-based breast reconstruction’ (IBBR) after mastectomy. Because it is still unknown what technique offers the best clinical outcomes, a multicenter retrospective study was conducted to compare both breast reconstruction techniques.MethodsAll patients, who underwent a mastectomy followed by immediate one- or two-stage IBBR during 2010 - 2016 were included. Our primary outcome measure was explantation of the ‘tissue expander’ (TE) and/ or implants within 60 days after breast reconstruction. Secondary outcomes were overall complication rate and secondary corrections.FindingsAmong a total of 383 women, TE/ implant explantation rate was higher in one-stage (19.9%) than in two-stage (11.3%) treated patients (p = 0.082). Overall complication rate (35.7% and 19.9% respectively, p = 0.008) and secondary corrections (29.8% and 20.3% respectively, p = 0.156) were also higher in one-stage compared to two-stage IBBR respectively. However, explantation (OR = 1.55; 95%CI = 0.67-3.58, p = 0.301) and complication (OR = 1.85; 95%CI = 0.92-3.37, p = 0.084) rates were comparable in one- and two-stage IBBR in our stratified multivariate logistic regression analyses, when controlling for history of smoking, nipple-sparing mastectomy, neoadjuvant radiation therapy, and removed breast tissue weight. A remarkable outcome in this study is that women treated with prophylactic surgery were more likely to have an explantation of the TE/ implant after a one-stage IBBR (OR = 4.49; 95%CI = 1.10-18.3, p = 0.037) than two-stage IBBR. In contrast, no association between type of IBBR and risk of TE/implants removal was found among women with a therapeutic mastectomy (OR = 0.82; 95%CI = 0.24-2.79, p =  = 0.74).ConclusionOne- and two-stage IBBR showed a comparable explantation and complication rate in our retrospective study. In one-stage IBBR more secondary corrections were detected. In addition, women who have to decide on a prophylactic mastectomy should be aware of a significantly higher risk of explantation of their implant after one-stage IBBR.     

Immediate breast reconstruction with expander in pregnant breast cancer patients

BackgroundBreast reconstruction after mastectomy is currently considered an essential component in managing breast cancer patients, particularly those diagnosed at a young age. However, no studies have been published on the feasibility of immediate breast reconstruction in patients diagnosed and operated during the course of gestation.MethodWe retrospectively identified all breast cancer patients who were subjected to mastectomy and immediate breast reconstruction during pregnancy at the European Institute of Oncology between 2002 and 2012. Patient demographics, gestational age at surgery, tumor stage, adjuvant treatment, details of the surgical procedures, surgical outcomes and fetal outcomes were analyzed.ResultsA total of 78 patients with breast cancer diagnosed during pregnancy were subjected to a surgical procedure during the course of gestation. Twenty-two patients had mastectomy; of whom 13 were subjected to immediate breast reconstruction. Twelve out of 13 patients had a two-stage procedure with tissue expander insertion. Median gestational age at surgery was 16 weeks. No major surgical complications were encountered. Only one patient elected to have an abortion, otherwise, no spontaneous abortions or pregnancy complications were reported. Median gestational age at delivery was 35 weeks (range: 32–40 weeks). No major congenital malformations were reported. At a median follow-up of 32 months, all patients are alive with no long-term surgical complications.ConclusionsThis is the first study of immediate breast reconstruction in pregnant breast cancer patients. Tissue expander insertion appears to ensure a short operative time, and does not seem to be associated with considerable morbidity to the patient or the fetus. Hence, it could be considered in the multidisciplinary management of women diagnosed with breast cancer during pregnancy.     

Laser-assisted indocyanine green angiography in implant-based immediate breast reconstruction: a retrospective study

Objective: Necrosis in implant-based immediate breast reconstruction is a feared complication. Accurate evaluation of mastectomy skin flaps per-operatively is necessary to decrease this risk. The present study is the first in Scandinavia to review the effects of perioperative evaluation with laser-assisted indocyanine green fluorescence angiography (LA-ICGA).

Method: A retrospective review was performed using data from the electronic patient record at the Department of Plastic and Breast Surgery at Aarhus University Hospital in Denmark on all patients who underwent implant-based skin-sparing immediate breast reconstruction with ADM in the time period March 2012 to October 2015. A total of 92 patients undergoing 128 breasts reconstructions were included in the study. An evaluation of complications before and after the implementation of LA-ICGA was performed.

Results: No significant difference in necrosis rates requiring surgical revision (p?=?.411) or conservative treatment (p?=?.149) in patients undergoing implant-based immediate breast reconstruction were found.

Conclusion: Our results differ from previously published studies in that no beneficial effect on necrosis rates of was found after implementing LA-ICGA, possibly due to our limited sample size.     

Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps

Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.     

Neoadjuvant therapy and breast cancer surgery: a closer look at postoperative complications

Background

Neoadjuvant therapy is important in the treatment of advanced breast cancer.

Methods

Postoperative complications in neoadjuvant patients were analyzed.

Results

One hundred forty patients underwent 148 breast cancer surgeries after neoadjuvant therapy: 28% breast-conserving therapy procedures, 36% mastectomies, 28% mastectomies with immediate reconstruction, and 8% mastectomies with delayed reconstruction. Forty-seven patients (34%) suffered 59 complications: 18% of those undergoing breast-conserving therapy, 30% of those undergoing mastectomy, 44% of those undergoing mastectomy with immediate reconstruction, and 67% of those undergoing mastectomy with delayed reconstruction. Major complications occurred in 18% of patients. Skin loss occurred in 6% of patients. One patient had partial nipple necrosis. Three patients suffered implant loss. One patient had deep inferior epigastric artery perforator flap loss. Eleven hematomas and 5 infectious complications required reoperation.

Conclusions

Surgery after neoadjuvant therapy is safe, but careful counseling is warranted given that 18% of patients experienced major complications. Complications rates are higher with reconstruction, but feared complications of skin, nipple, implant, or flap loss were infrequent.     

Post-mastectomy reconstruction: A risk-stratified comparative analysis of outcomes

IntroductionAlthough breast reconstruction following mastectomy plays a role in the psychological impact of breast cancer, only one in three women undergo reconstruction. Few multi-institutional studies have compared complication profiles of reconstructive patients to non-reconstructive.MethodsUsing the National Surgical Quality Improvement database, all patients undergoing mastectomy from 2006 to 2010, with or without reconstruction, were identified and risk-stratified using propensity scored quintiles. The incidence of complications and comorbidities were compared.ResultsOf 37,723 mastectomies identified, 30% received immediate breast reconstruction. After quintile matching for comorbidities, complications rates between reconstructive and non-reconstructives were similar. This trend was echoed across all quintiles, except in the sub-group with highest comorbidities. Here, the reconstructive patients had significantly more complications than the non-reconstructive (22.8% versus 7.0%, p < 0.001).ConclusionImmediate breast reconstruction is a well-tolerated surgical procedure. However, in patients with high comorbidities, surgeons must carefully counterbalance surgical risks with psychosocial benefits to maximize patient outcomes.Level of evidenceLevel 3     

Innovative combination of therapeutic mammoplasty and expandable-implant breast augmentation for immediate partial breast reconstruction

IntroductionTherapeutic mammoplasty is used in the treatment of suitably-sized and appropriately-located breast cancers to achieve adequate cancer excision, resulting in well-shaped but smaller breasts. In patients wishing to maintain or increase their breast size, simultaneous augmentation will be required.Presentation of caseA 48-year-old female underwent an “augmentation-therapeutic mastopexy”. She required mastectomy for a multifocal cancer of the right breast and breast conservation for a unifocal localised cancer in the upper part of the left breast. She requested right immediate breast reconstruction and hoped for larger breasts than she had. Due to complications during neoadjuvant chemotherapy, the right reconstruction plan was changed from a deep inferior epigastric perforator (DIEP) flap to an implant-based technique. On the left, an extended superomedial pedicle therapeutic mammoplasty was combined with a subpectoral augmentation using an expandable-implant.DiscussionThe use of expandable-implants for reconstruction of partial mastectomy defects in combination with therapeutic mammoplasty has not been reported. This case report shows that such “augmentation-therapeutic mastopexy” is feasible.ConclusionA “novel” oncoplastic technique herein termed “augmentation-therapeutic mastopexy” is described for partial breast reconstruction during the treatment of a patient with bilateral breast cancer. It enabled adequate treatment of her cancer while reshaping the breast and achieving the desired larger breast size. It should be considered in selected breast-conservation patients who wish to maintain or increase their breast size.     

Delayed‐immediate hybrid breast reconstruction—Increasing patient input and precision in breast reconstruction

The benefits of breast reconstruction via free tissue transfer with simultaneous implant placement, that is, hybrid breast reconstruction, in select patients are well‐known. Challenges exist, however, and are related to proper implant selection as well as postoperative mastectomy skin necrosis. Here, the authors present an approach that increases reconstructive precision while minimizing postoperative mastectomy skin necrosis. A retrospective analysis of patients who underwent immediate prepectoral tissue expander placement (stage 1) followed by delayed‐immediate hybrid breast reconstruction (stage 2) was performed. Parameters of interest included patient demographics, postoperative complications, and revision rates. A total of 31 patients with a mean age of 48.7 years (range, 30‐67 years) and a mean BMI of 26.3 kg/m² (range, 21.0‐35.3 kg/m²) who underwent bilateral breast reconstruction were included. Of the 62 free abdominal flaps, 45 (72.6%) and 17 (27.4%) were MS‐TRAM and DIEP flaps, respectively. The most common implant volume was 240 cc (range, 140‐445 cc). Following stage 1, minor and major complications were observed in nine (29%) and one (3.2%) patients, respectively. No major complications were noted after stage 2. Of note, no patient developed mastectomy skin necrosis or requested a change in implant size following stage 2. Delayed‐immediate hybrid breast reconstruction improves the ability to more precisely match patient expectations related to breast size and is associated with a reduction in the rate of mastectomy skin necrosis following the critical second stage of reconstruction.     

Breast reconstruction following nipple-sparing mastectomy: clinical outcomes and risk factors related complications

Background: The aim of this study was to investigate clinical outcomes and risk factors related complications in patients who had undergone nipple-sparing mastectomy (NSM) followed by implant-based or autologous reconstruction.

Methods: Between 2004–2014 a single-institution retrospective review was collected on NSMs reconstruction. Patient demographics, comorbidities, breast morphological factors, type and timing of radiotherapy, type of incision, reconstruction type and timing, implant volume and complications were collected.

Results: A total of 288 patients had undergone 369 NSMs, 81 (28.1%) of which were bilateral while 207 (71.9%) unilateral. One-hundred mastectomies were performed for prophylactic purposes whereas 269 were therapeutics. Thirteen (4.5%) patients were active smokers, while 2 (0.7%) were diabetics. Fifty-five breasts (14.9%) were previously irradiated and average time elapsed between radiotherapy and NSM was 9-year, (range, 5–15 yrs). Total complication rate was 13.5% at mean follow-up of 47.98?months (range, 6–114?months). Partial-thickness and full-thickness mastectomy skin flap and NAC necrosis occurred in 39 (78%) and in 10 (20%) breasts, respectively. Previous radiotherapy and implant volume were significant predictors of complications (OR: 10.14, 95% CI: 3.99–27.01; OR?×?100?g: 3.13, 95% CI: 1.64–6.33). Overall mastectomy type incision was not predictive of complications (p?=?.426). No association was observed between radiotherapy and mastectomy type access (p?=?.349).

Conclusions: From our experience NSM followed by implant-based and autologous reconstruction had a relative high rate of complications comparable to previous reports. Despite this, it should be carefully offered to patients in whom potential risk factors are identified.     

Complications,risk factors,and patients-reported outcomes after skin-sparing mastectomy followed by breast reconstruction in women with BRCA mutations

Background: Women with a BRCA mutation have the option of undergoing prophylactic mastectomy and immediate breast reconstruction; however, the potential negative effects of reconstruction on women’s physical and psychological well-being are unclear. This study aimed to investigate complications, patient-reported pain, health-related quality-of-life (HRQoL) and satisfaction following reconstructive surgery at Oslo University Hospital between 2006 and 2013.

Methods: Data were collected retrospectively from the records of 238 patients. A cross-sectional survey was conducted to collect patient-reported HRQoL and satisfaction with outcome using the Short Form-12 questionnaires and Breast-Q. The self-administered Leeds assessment of neuropathic symptoms and signs was used to assess neuropathic pain.

Results: The majority of participants (89.5%) underwent implant-based breast reconstruction (IBBR); the remainder underwent autologous-tissue breast reconstruction (ATBR). Overall, 28.6% had complications within 30?days of surgery and 14.6% required resurgery because of complications. Women who underwent IBBR had a later onset of complications than those undergoing ATBR. Participants in the survey (n?=?175 of 219, response rate 79.9%) reported similar HRQoL to an age-matched general female population. Few (2.9%) reported neuropathic pain. Patients who underwent IBBR were significantly less satisfied with the reconstructed breast (p?=?.001) and overall outcome (p?=?.02) than those who underwent ATBR, but there were no significant differences in HRQoL scores between the two groups.

Conclusions: Overall, 28.6% of the women had complications within 30?days and 14.6% needed resurgery. Few had neuropathic pain. Women who underwent ATBR were more satisfied with the overall outcome than those who underwent IBBR.     

Are patients with low body mass index candidates for deep inferior epigastric perforator flaps for unilateral breast reconstruction?

Thin women have not traditionally been considered ideal candidates for autologous breast reconstruction. The purpose of this study was to examine the use of deep inferior epigastric perforator (DIEP) flap reconstruction in thin women undergoing immediate unilateral breast reconstruction. A retrospective review of 1,040 consecutive patients was performed. In total, 381 patients met the inclusion criteria. To improve clinical interpretability, patients were divided into three groups based on body mass index: “thin” (BMI ≤ 22.99), “traditional” (>23 and ≤29.99), and “obese” (BMI >30) candidates. Flap characteristics were compared to mastectomy weights, and postoperative complications were analyzed. In all groups, flap size was generally more than sufficient to match the mastectomy specimen, as flap weight:mastectomy weight ratio ws greater than 1 in all groups with no significant difference between groups (1.1 in thin patients, 1.0 in traditional patients, and 1.0 in obese patients). Fat necrosis prevalence was lowest in the thin group (12.5%), compared to the traditional (15.9%, P = 0.443) or obese (14.4%, P = 0.698) groups. Prevalence of breast infection were lower in the thin patients (5.2%) versus the traditional (8.7%, P = 0.287) or obese (14.4%, P = 0.033). Abdominal wound healing complications and seroma were also lowest in thin patients. DIEP flap breast reconstruction may be an effective method for unilateral breast reconstruction in thin patients, with sufficient flap weights and lower incidence of complications than in heavier patients. As such, low BMI may not present a barrier in the reconstruction of a breast mound matching native breast size. © 2015 Wiley Periodicals, Inc. Microsurgery 35:421–427, 2015.     

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS?

Background: Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients. Methods and Results: We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography. Conclusion: We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.     

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

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.MethodsData for 67,450 patients undergoing mastectomy for breast cancer were analyzed using the National Surgical Quality Improvement Program (NSQIP) database for years 2005-2014. Primary outcomes were wound, nonwound related infections, and bleeding complications. Data were analyzed by univariate and multivariate analysis.ResultsThe percentage of patients that underwent reconstruction after breast cancer increased from 26.94% in 2005 to 43.30% in 2014 (p < 0.01). There was increased wound (5.59%), bleeding (6.82%), and infection (1.80%) complications after flap-based reconstruction (p < 0.01). There was no difference in wound, infection, and bleeding complications between immediate implant reconstruction and tissue expander (TE) at 4.38 vs. 3.89% (p = 0.18), 0.82 vs. 0.7%, p = 0.46), and 0.76 vs. 0.64% (p = 0.45), respectively. Several independent factors were associated with increased wound complications in patients undergoing all or any forms of reconstruction after mastectomy such as being overweight (OR 1.38, CI 1.23–1.55), obese (OR 2.11, CI 1.89–2.35), morbidly obese (OR 3.84, CI 3.34-4.43), ASA Class III (OR 1.35, CI 1.08-1.69), ASA Class IV (OR 1.49, 1.06-2.10), diabetic (OR 1.28 , CI 1.14–1.43), and smokers (OR 1.76, CI 1.59–1.94). TRAM flap was associated with increased risk of wound complication (OR 1.87, CI 1.28–2.75).ConclusionMore women are undergoing reconstruction as utilization of TE increases drastically. Immediate implant placement has only seen moderate increase likely due to surgeon preference.