The Timing of Breast Irradiation in Two‐Stage Expander/Implant Breast Reconstruction

Certain patients who initiate expander/implant (E/I) reconstruction following mastectomy may require radiation therapy (XRT). XRT may be delivered during the tissue expander (TE) expansion process or after exchange for a permanent implant (PI). We studied a series of women treated with E/I reconstruction and XRT to determine whether there is a difference in complication rates between those who had XRT to the TE versus PI. All two‐stage E/I reconstructions at our institution from April 2005 to January 2013 were reviewed to identify patients who underwent XRT after TE placement. Our database was queried for reconstructive details, oncologic treatment, and complications. Statistical analyses were performed to establish significance of complication rate differences. Fifty‐two patients underwent XRT after TE placement, 42 of which had XRT to the TE and 11 of which had XRT to the PI. The major complication rates (complications requiring emergent reoperation/readmission) were 27% versus 0% (p = 0.05) for XRT to the TE versus XRT to the PI, but there were no significant differences in minor complication rates (outpatient complications). Specifically, the rates of Grade 3/4 capsular contracture were similar between the two groups, 27% for the XRT to the TE group and 36% for the XRT to the PI group. Radiation of the PI versus radiation of the TE did not result in significant differences in overall surgical complication rates but had fewer major complications and no implant failures. Other factors must also be considered, such as patient preference, risk of cancer reoccurrence, and cosmesis. It is essential for a patient to have a team of a plastic surgeon and radiation, surgical, and medical oncologists working together to achieve each patient's goals.     

Feasibility of Immediate Breast Reconstruction for Locally Advanced Breast Cancer

Background: Immediate breast reconstruction (IBR) has been considered contraindicated for patients with locally advanced breast cancer (LABC). Our goal was to determine whether IBR resulted in delayed postoperative chemotherapy, increased postoperative complications, or increased risk of recurrent disease.Methods: A prospective database of 540 modified radical mastectomies performed with IBR between 1990 and 1993 identified 50 patients with LABC. Postoperative management and outcome were compared to that of 72 patients undergoing modified radical mastectomy without IBR treated on a standardized LABC protocol using preoperative chemotherapy, postoperative chemotherapy, and radiotherapy during the same time period.Results: Results were evaluated by 2 analysis. The median ages for the patients with IBR versus those not undergoing IBR were 44 and 46 years, respectively. The stage distribution for the IBR patients versus patients not undergoing IBR was as follows: IIB, 46% versus 17%; IIIA, 44% versus 39%; and IIIB, 10% versus 44%. The types of IBR were transverse rectus abdominis myocutaneous (TRAM) flap (68%), latissimus dorsi flap (2%), and implants (30%). Chemotherapy was given to all IBR patients: 24% preoperatively and 96% postoperatively. Radiotherapy was used in 40%. Four postoperative complications (8%) necessitated prolongation of hospitalization, including two patients requiring surgical debridement for partial flap loss; there were no complete flap losses. The incidences of major and minor wound complications in the group not undergoing IBR were 7% and 4%, respectively. Of the 15 patients receiving implant reconstruction, 7 (47%) required subsequent implant removal because of contractures or infections. The median interval between surgery and postoperative chemotherapy was 35 days for the IBR patients and 21 days for the patients not undergoing IBR. This difference was marginally significant (P 5.05). With a median follow-up of 58.4 months, no significant differences in local or distant relapse rates were detected.Conclusions: IBR can be performed with low morbidity in patients with LABC. Use of autogenous tissue is preferable because of poor results with implants. IBR is associated with somewhat longer intervals to resumption of postoperative chemotherapy, but this does not appear to be clinically significant—the local and distant relapse rates are similar for LABC patients undergoing modified radical mastectomy with or without IBR.     

Extending the Indications for Autologous Breast Reconstruction Using a Two‐Stage Modified Goldilocks Procedure: A Case Report

Post‐mastectomy reconstruction is performed using implant‐based or autologous techniques. Many women refuse or are poor candidates for implant‐based reconstruction. We previously described a single‐stage autologous technique that was most applicable in obese women with significant ptosis that made use of the mastectomy skin flap and subcutaneous tissue to reconstruct a breast mound. Here, we extend this technique to smaller breasted women by incorporating a second stage of skin tailoring and fat grafting. This technique does not require donor site surgery nor extended operative and recovery times. It extends the indications for autologous reconstruction to nonideal candidates and to developing countries where cost limits access.     

延迟——即刻乳房再造

延期—即刻乳房再造是在乳癌根治术后一期,于胸大肌后植入合适大小扩张器,定期注水扩张,二期置换为乳房假体,根据术后放疗与否选择二期手术时机。延期—即刻乳房再造为可能需要接受术后放疗的患者提供了更好的乳房再造效果,降低了并发症的发生率。本文就延期—即刻乳房再造的适应证及手术方法进行综述。     

Breast Reconstruction National Trends and Healthcare Implications

Breast reconstruction improves quality‐of‐life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant‐based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.     

Breast Reconstruction after Bilateral Prophylactic Mastectomy in Women at High Risk for Breast Cancer

Abstract:  Several studies have shown the effectiveness of bilateral prophylactic mastectomies (BPM) at reducing the risk of developing breast cancer in women by more than 90%. A growing number of women at high risk for breast cancer are electing to undergo prophylactic mastectomy as part of a risk reduction strategy. This unique group of women frequently chooses to undergo reconstructive surgery as a part of their immediate treatment plan. Breast reconstruction after BPM has profound physiological and emotional impact on body image, sexuality, and quality of life. These factors should be taken into consideration and addressed when consulting the patient prior to BPM and reconstructive surgery. The timing of reconstructive surgery, the type of mastectomy performed, the reconstructive modalities available, and the possibility to preserve the nipple–areola complex, should all be discussed with the patient prior to surgery. In this article, we review our experience and the current existing literature on breast reconstruction for high-risk women after BPM.     

Survival in Breast Cancer Patients Undergoing Immediate Breast Reconstruction

Abstract: Immediate and early‐delayed breast reconstruction are the preferred methods of reconstruction in breast cancer patients treated with mastectomy. These options for reconstruction allow for superior outcomes through peri‐operative planning between the oncologic surgeon and reconstructive team. We used the Surveillance, Epidemiology, and End Results (SEER) database to study the overall survival of patients treated with immediate or early‐delayed breast reconstruction after mastectomy. Population level de‐identified data was abstracted from the National Cancer Institute’s SEER cancer database. We obtained data for all female patients with breast cancer treated with mastectomy from 2000 to 2002. Patients with missing or incomplete data were excluded. Univariate and multivariate statistics were performed using Intercooled Stata 7.0 (College Station, TX). A total of 51,702 patients were included in the study. The mean age was 60.8 (range 20–104) years old. Reconstruction was performed in 16.7% of patients. Multivariate analysis showed that patients treated with mastectomy and reconstruction had a significantly lower hazard ratio of death (HR = 0.62, p < 0.001) compared with patients treated with mastectomy only, when controlling for demographic and oncologic covariates. Black patients comprised 7.5% of the total population, and multivariate analysis showed that black patients had a significantly increased hazard ratio of death (HR = 1.43, p < 0.001) when compared with white patients, when controlling for all other covariates including reconstruction status. We show that women with breast cancer who undergo breast reconstruction after mastectomy do not have a worse overall survival than those not undergoing breast reconstruction. This is true when patient age, race, income, and marital status; and tumor stage, histology, grade, use of radiotherapy, and mastectomy site (bilateral or unilateral) are controlled for.     

Pedicled or Free Flap from Contralateral Breast for Autologous Breast Reconstruction

BackgroundThrough precise understanding of the vascular anatomy of the breast, the lower segment of the breast could be harvested as a pedicled or free flap for contralateral breast reconstruction.Case presentationIn case 1, based on the 4th internal thoracic artery perforator, the pedicled flap from the breast was transferred to the contralateral side for immediate breast reconstruction. In case 2, with the thoracoacromial vascular pedicle, the free flap from the healthy breast was harvested for delayed breast reconstruction on the contralateral side.ResultsBoth flaps survived well postoperatively. A certain degree of asymmetry was observed in both cases, but the patients were satisfied with the overall results. At the end of follow-up, no tumor recurred in either breast.ConclusionIn patients with a large healthy breast, the lower segment could be harvested as a pedicled or free flap for contralateral breast reconstruction.     

Revisiting an Old Place: Single‐Surgeon Experience on Post‐Mastectomy Subcutaneous Implant‐Based Breast Reconstruction

Significant advances have been made to the reconstructive tools available to plastic surgeons allowing for the re‐exploration of subcutaneous breast reconstruction. The purpose of the current study is to examine the safety, efficacy, and aesthetic results of subcutaneous breast reconstruction by a single‐surgeon. A retrospective chart review was performed on all patients undergoing subcutaneous implant‐based breast reconstruction between April 2012 and September 2014. All implants were fully wrapped in Alloderm and placed in the subcutaneous (pre‐pectoral) plane. Primary outcome was a successful subcutaneous breast reconstruction. All complications were recorded. Aesthetics of the preoperative and postoperative photographs were examined. A total of 135 breasts (79 patients) were reconstructed. Direct‐to‐implant reconstruction was performed in 8 patients (10%). Successful breast reconstruction was achieved for 130 breasts in 76 patients (96%). Sixty‐nine patients (87%) had a course free of any unexpected event or complication. There were no patients with implant extrusion or skin necrosis requiring operative intervention. When comparing pre‐mastectomy breasts with post‐mastectomy reconstructions, there was an improvement in the overall aesthetic outcome. Subcutaneous post‐mastectomy breast reconstruction is safe and effective with comparable complication rates to standard techniques. Yet, this minimally invasive approach does not sacrifice the aesthetic results. Long‐term studies will be required to prove the durability of aesthetic results overtime.     

A Possible Technique for the Complex Reconstruction of Exposed Breast Implant: Applicability and Microcirculation of the Capsule Flap

Abstract

Aim of the Study: Immediate breast reconstruction is often applied after mastectomy. However, inappropriate surgical technique, postoperative radiotherapy and infection may lead to tissue necrosis and implant protrusion. Traditional therapies frequently fail. However, previous data suggested that capsule flaps may be appropriate for the salvage of implants. Our goal was to investigate the usefulness of capsuloplasty in patients with exposed breast implant and to monitor the blood supply of capsule flaps during the operation. Materials and Methods: Capsuloplasty was performed in 19 patients with exposed implant. After removal of necrotic tissue, capsulotomy was performed, the planned flap was dissected free, the implant was covered with the flap and the wound was then closed. During operation, the blood flow of the flap was determined by means of laser Doppler flowmetry. Moreover, tissue samples were taken for histology and immunostaining for CD34. Results: The postoperative follow-up showed that capsule flaps survived in each case: no complications were found. The blood flow of the flaps did not change significantly during the intervention as compared with the baseline values. The histology and the immunohistochemistry revealed considerable vascularization and angiogenesis in the flap. Conclusions: Capsule flaps seem to be appropriate for the salvage of exposed implants and for enhancement of implant cover in the case of thin and injured tissue.     

Sensation Following Immediate Breast Reconstruction with Implants

Sensation is a neglected aspect of the outcome of breast reconstructions with implants. The aim of this prospective study was to evaluate the cutaneous somatosensory status in breasts following mastectomy and immediate reconstruction with permanent adjustable prostheses and to analyze the patients' subjective experience of the sensation. Twenty-four consecutive patients diagnosed with invasive or in situ breast carcinoma were examined preoperatively and 2 years after mastectomy and reconstruction, for assessment of perception thresholds for touch, cold, warmth, and heat pain above and below the areola. Von Frey filaments and a Peltier element-based thermode were used. The patients completed a questionnaire concerning their experienced sensation in the reconstructed breast. Using quantitative somato-sensory testing, the sensation to all the examined modalities was significantly impaired compared to preoperatively. Most affected was the area above the areola. Patients given postoperative radiotherapy (n = 9) did not differ from those without radiotherapy (n = 15) regarding any of the modalities. All patients reported reduced sensation in the reconstructed breast compared to that preoperatively. Twenty-three patients stated that the reconstructed breast felt different from the other breast; nevertheless 16 reported that the reconstructed breast felt like a real breast. The study revealed sensation impairment following mastectomy and immediate reconstruction with implants. Patients should be informed about this effect preoperatively to allow adequate expectations regarding the sensation outcome. However, two-thirds of the study patients considered that the reconstructed breast felt like a real breast, which must be one of the main purposes of a breast reconstruction.