Thursday, 15 February 2018

Germline BRCA mutation and outcome in young-onset breast cancer (POSH): a prospective cohort study

 Germline BRCA mutation and outcome in young-onset breast cancer (POSH): a prospective cohort study

Copson ,E et al
Lancet Oncology Volume 19, No. 2, p169–180, February 2018

Patients with young-onset breast cancer who carry a BRCA mutation have similar survival as non-carriers. However, BRCA mutation carriers with triple-negative breast cancer might have a survival advantage during the first few years after diagnosis compared with non-carriers. Decisions about timing of additional surgery aimed at reducing future second primary-cancer risks should take into account patient prognosis associated with the first malignancy and patient preferences.

The Lateral Thigh Perforator Flap for Autologous Breast Reconstruction: A Prospective Analysis of 138 Flaps

The Lateral Thigh Perforator Flap for Autologous Breast Reconstruction: A Prospective Analysis of 138 Flaps

Tuinder, S et al
Plastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 -  p 257–268

Background: The septocutaneous tensor fasciae latae or lateral thigh perforator flap was previously introduced by the authors’ group as an alternative flap for autologous breast reconstruction when the abdomen is not suitable as a donor site. The authors analyzed their experience with the lateral thigh perforator flap and present the surgical refinements that were introduced. 
Methods: A prospective study was conducted of all lateral thigh perforator flap breast reconstructions performed since September of 2012. Patient demographics, operative details, complications, and flap reexplorations were recorded. Preoperative imaging with magnetic resonance angiography was performed in all patients. Surgical refinements introduced during this study included limitation of the flap width and the use of quilting sutures at the donor site. 
Results: A total of 138 lateral thigh perforator flap breast reconstructions were performed in 86 consecutive patients. Median operative times were 277 minutes (range, 196 to 561 minutes) for unilateral procedures and 451 minutes (range, 335 to 710 minutes) for bilateral. Median flap weight was 348 g (range, 175 to 814 g). Two total flap losses (1.4 percent) were recorded, and 11 flaps (8.0 percent) required reexploration, which resulted in viable flaps. The incidence of donor-site complications was reduced significantly after the surgical refinements were introduced. Wound problems decreased from 40.0 percent to 6.3 percent, seroma decreased from 25.0 percent to 9.5 percent, and infection decreased from 27.5 percent to 9.5 percent. 
Conclusions: The lateral thigh perforator flap is an excellent option for autologous breast reconstruction, with minimal recipient-site complications. The surgical refinements resulted in a significant reduction of donor-site complications. Therefore, the lateral thigh perforator flap is currently the authors’ second choice after the deep inferior epigastric artery perforator flap.

Venous Superdrainage in DIEP Flap Breast Reconstruction: The Impact of Superficial Inferior Epigastric Vein Dissection on Abdominal Seroma Formation

Venous Superdrainage in DIEP Flap Breast Reconstruction: The Impact of Superficial Inferior Epigastric Vein Dissection on Abdominal Seroma Formation

Nedomansky, J et al
Plastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 206e–212e

Background: Abdominal seroma formation after deep inferior epigastric perforator (DIEP) flap breast reconstruction is a common donor-site complication. Additional dissection of one or both of the superficial inferior epigastric veins (SIEVs) in DIEP flap breast reconstruction allows an additional anastomosis for venous superdrainage if venous congestion occurs. However, generally, SIEV dissection involves greater invasiveness into the inguinal region, which can traumatize lymphatic tissue and lead to lymph accumulation. The aim of this study was to evaluate the impact of SIEV dissection on the incidence of postoperative abdominal seroma. 
Methods: A series of 100 consecutive cases performed by the Department of Plastic and Reconstructive Surgery at the Medical University of Vienna from 2001 to 2016 was analyzed. Patients were divided into three groups: unilateral, bilateral, and no SIEV dissection. Abdominal seroma rates, length of hospital stay, abdominal drainage duration, and drainage fluid volumes were compared retrospectively. 
Results: Seromas were observed in 11.5 percent of patients without SIEV dissection, 17.2 percent of patients with unilateral SIEV dissection (p = 0.45 versus no SIEV), and 40 percent of patients with bilateral SIEV dissection (p = 0.02 versus no SIEV). The SIEV was anastomosed to salvage a congested DIEP flap twice. All seromas that developed could be treated with, on average, two fine-needle aspirations without any complications. 
Conclusions: Bilateral, but not unilateral, SIEV dissection increased abdominal seroma rates significantly. Venous congestion was observed rarely, but when it did occur, it endangered flap viability. Because an additional anastomosis of the SIEV can salvage a flap, unilateral SIEV dissection should be considered when raising a DIEP flap.

Plastic Surgeon–Led Ultrasound

Plastic Surgeon–Led Ultrasound

Oni, G et al
Plastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 300e–309e

Background: Portable high-frequency ultrasound is a useful adjunct to a plastic surgeon's practice. With a short learning curve, this patient-friendly imaging modality has a variety of uses that aid patient management/treatment plans. The authors describe clinical cases and review the literature regarding ultrasound performed by the surgeon. 
Methods: The Sonosite S-Nerve machine with the L25X transducer was used (depth, 4.3 cm). Clinical cases that ordinarily would have been referred to the radiology department were taken from the day-to-day practice of the senior author (M.G.). The clinical scenarios ranged from acute presentations to planned elective settings. 
Results: Ultrasound was a useful adjunct in a variety of applications, ranging from acute hand trauma visualizing neurovascular bundles and tendons, to elements of reconstructive breast surgery such as fat grafting over an implant and scar release. The ultrasound machine was also used for determination of the depth and size of collections such as seromas to facilitate drainage, for identification of lymph nodes before transfer, and for acute presentations of conditions ranging from undiagnosed swelling to foreign body localization. 
Conclusions: The portable ultrasound machine has become an invaluable tool in the senior author’s practice. In a short time and with a short learning curve, the authors’ unit identified numerous applications for its use. From a patient perspective, it is noninvasive/nonpainful and has no deleterious radiation effects, and treatment plans can be enacted without delay. It is highly recommended that surgeons become familiar with this imaging modality and assimilate it into their daily practice

The Comparison of Strattice and SurgiMend in Acellular Dermal Matrix–Assisted, Implant-Based Immediate Breast Reconstruction

The Comparison of Strattice and SurgiMend in Acellular Dermal Matrix–Assisted, Implant-Based Immediate Breast Reconstruction
Mazari, F et alPlastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 283–293Background: Strattice (porcine derivative) and SurgiMend (bovine derivative) are the two most common acellular dermal matrices used in breast reconstruction in the United Kingdom. This retrospective study compared clinical outcomes in immediate implant-based breast reconstruction patients. 
Methods: The study, conducted across three hospitals, included all patients who underwent immediate implant-based breast reconstruction using Strattice and SurgiMend. The primary outcome measure was implant loss rate. Secondary outcome measures included acellular dermal matrix loss rate, seroma formation, and minor and major complication rates. Intergroup comparison was performed. 
Results: Eighty-two patients (Strattice, n = 45; SurgiMend, n = 37) underwent 97 immediate implant-based breast reconstructions (Strattice, n = 54; SurgiMend, n = 43). There were no differences between groups for age, comorbidities, specimen weight, or implant volume. Drains were used in all Strattice and 36 (84 percent) SurgiMend cases. The implant loss rate was higher for Strattice (n = 10, 20 percent) compared with SurgiMend (n = 3, 7 percent) but failed to reach statistical significance (chi-square test, p = 0.077). The acellular dermal matrix loss rate was significantly higher (Fisher’s exact test, p = 0.014) in the Strattice group (n = 7, 14 percent), with no acellular dermal matrix loss with SurgiMend. The reoperation rate was also significantly higher (chi-square test, p = 0.002) in the Strattice group (n = 17, 33 percent, versus n = 3, 7 percent). The incidence of red breast was significantly higher (chi-square test, p = 0.022) in the SurgiMend group (n = 9, 21 percent, versus n = 3, 6 percent). Seroma, wound problems, and infection rates were similar. 
Conclusions: Clinical outcomes, including implant loss, acellular dermal matrix loss, and reoperation rates, are significantly better when using SurgiMend in immediate implant-based breast reconstruction compared with Strattice. An appropriately powered randomized trial is needed to provide further information. 

Bovine Acellular Dermal Matrix in Immediate Breast Reconstruction: A Retrospective, Observational Study with SurgiMend

Bovine Acellular Dermal Matrix in Immediate Breast Reconstruction: A Retrospective, Observational Study with SurgiMend

Scheflan, M et al
Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 1e–10e

Background: Acellular dermal matrices can be combined with implant-based breast reconstruction to help optimize outcomes. SurgiMend PRS is a fetal bovine dermis–derived acellular dermal matrix composed of type I collagen and approximately 30 percent type III collagen, sharing many of the properties of human cadaveric acellular dermal matrix. 
Methods: This was a retrospective, single-center analysis of 111 adult patients (147 breasts) undergoing one-stage (83.7 percent) or two-stage (16.3 percent) immediate breast reconstruction after mastectomy. The aims were to characterize the safety profile of SurgiMend and investigate associations between risk factors and complications.
Results: The mean age of the patients was 47.9 years and the mean body mass index was 24.7 kg/m2. After a median follow-up of 24.3 months, the overall rates of minor and major complications were 25.2 percent (n = 37 of 147) and 12.9 percent (n = 19 of 147), respectively. The most common major complications were seroma [n = 12 (8.2 percent)] and necrosis [n = 9 (6.1 percent)]. All occurred within 3 months after surgery. The rate of capsular contracture was 2.7 percent (n = 4). A total of 2.7 percent of implanted breasts (n = 4) required explantation. In a univariate analysis, smokers had a greater risk of major complications (p = 0.013), and postoperative radiation therapy and obesity were associated with an increased risk of capsular contracture (p = 0.006) and explantation (p = 0.006), respectively. In a multivariate analysis, several factors were associated with complications or explantation, including obesity (p < 0.05), preoperative chemotherapy (p < 0.001), and mastectomy weight (p < 0.05). These associations align with other studies of implant-based reconstruction and do not appear to be specific to this acellular dermal matrix. 
Conclusion: The results are consistent with previous analyses of SurgiMend, and support its value in implant-based breast reconstruction. 

Outcome Analysis of Free Flap Salvage in Outpatients Presenting with Microvascular Compromise

Outcome Analysis of Free Flap Salvage in Outpatients Presenting with Microvascular Compromise

Largo, R et al
Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 20e–27e

Background: Extensive flap salvage attempts are routinely performed in patients with late-onset flap vascular crisis despite low flap survival rates. A knowledge gap exists in management of compromised free flaps in patients who present with perfusion-related complications after hospital discharge. 
Methods: A retrospective review of 7443 free flaps used in 7128 cancer patients at a single institution from January of 2001 to March of 2015 was performed. 
Results: Of 7443 free flap reconstructions, 856 patients (12 percent) were taken back to the operating room. Also, 261 patients (4 percent) suffered from microvascular compromise, of whom 110 (1 percent) experienced total flap loss. The authors identified 17 patients (10 breast cancer patients and seven head and neck cancer patients) who had vascular flap compromise and underwent reoperation after hospital discharge (median, 10 days; range, 4 to 107 days) after free flap reconstruction. Of these 17 patients, nine breast cancer patients and two head and neck cancer patients underwent flap salvage attempts. Salvage procedures included thrombectomy, thrombolytic and heparin injections, and reanastomoses (11 patients); vein grafting (four patients); vein supercharging with cephalic turndown (two patients); and change of recipient vessels (two patients). Sixteen of the 17 patients (94 percent) experienced total flap loss, and one patient (6 percent) had partial flap loss requiring long-lasting wound treatment. 
Conclusions: Outpatient free flap salvage has a low success rate regardless of flap type, recipient site, or patient population. The authors’ study suggests that immediate second-line reconstruction is more effective for late-onset flap vascular crisis than extensive flap salvage procedures. 

22 Cases of Breast Implant–Associated ALCL: Awareness and Outcome Tracking from the Italian Ministry of Health

22 Cases of Breast Implant–Associated ALCL: Awareness and Outcome Tracking from the Italian Ministry of Health

Campanale, A et al 


Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 11e–19e

Background: To date, 359 cases of anaplastic large cell lymphoma (ALCL) in women with breast implants (breast implant–associated ALCL [BIA-ALCL]) worldwide have been reported among more than 10 million patients who have received implants, but health care authorities suspect this is a possible underestimation, and the limited number of cases makes it difficult to clarify its cause. The General Directorate of Medical Devices and Pharmaceutical Services of the Italian Ministry of Health has examined and studied the Italian BIA-ALCL cases. 
Methods: An official document has been diffused to all medical associations, aiming at encouraging all physicians to notify each BIA-ALCL case. A retrospective study has been performed on the notified BIA-ALCL cases collected in the database named Dispovigilance. Results: Research on Dispovigilance returns a list of 22 BIA-ALCL cases. The mean patient age was 49.6 years (range, 30 to 71 years). The average time to the onset of the symptoms was 6.8 years (range, 1 to 22 years). The average time to diagnosis was 7.8 years (range, 4 to 22 years). The estimated incidence of the Italian BIA-ALCL cases related to 2015 is 2.8 per 100,000 patients. Conclusions: The pathogenesis of BIA-ALCL remains unknown. The establishment of a national breast implant registry is needed to better understand some aspects of this disease. Future genetic studies on the population affected could clarify why only some patients with implants develop this disease.

Microbial Evaluation in Capsular Contracture of Breast Implants

Microbial Evaluation in Capsular Contracture of Breast Implants

Galdiero, M et al

Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 23–30

Background: Capsular contracture around breast implants is a severe and unpredictable complication experienced by up to 50 percent of patients after breast augmentation and reconstruction, and represents a major cause leading to reoperation. Several lines of evidence point to the involvement of subclinical infections and of bacterial biofilm formation. Methods: To reduce the incidence of capsular contracture following mammaplasty, the authors studied the correlation between contamination by exogenous and endogenous bacterial flora and the capacity to develop bacterial biofilm in mammary implants. The authors performed a microbiological study assessing microbial growth of swabs from breast skin, nipple-areola complex, and mammary gland biopsy specimens. Furthermore, the authors compared the results with the data resulting from cultural experiments from biopsy specimens of periprosthetic capsule, contracted or not, and from the surfaces of the relative prosthesis. 
Results: Between July of 2012 and July of 2013, a series of 65 female patients from the area of Naples, Italy, and its province, who underwent breast plastic surgery with the use of implants for aesthetic or reconstructive reasons, were included in the study. The authors noticed that there is a greater tendency for capsular contracture to form in oncologic patients who received radiotherapy, patients with precedent capsular contracture, and patients with cutaneous contamination by biofilm-producing microbes. 
Conclusions: Although all of the new technical procedures tend to reduce the amount of bacterial charge that comes into contact with the prosthesis at the time of its introduction, a minimal amount must always be taken for granted. This is the rationale for a preventative personalized antibiotic therapy.

Thursday, 11 January 2018

Acellular Dermal Matrix in Immediate Expander/Implant Breast Reconstruction: A Multicenter Assessment of Risks and Benefits

Acellular Dermal Matrix in Immediate Expander/Implant Breast Reconstruction: A Multicenter Assessment of Risks and Benefits

Sorkin M et al

Plastic and Reconstructive Surgery: December 2017 - Volume 140 - Issue 6 - p 1091–1100

Background: Acellular dermal matrix has gained widespread acceptance in immediate expander/implant reconstruction because of perceived benefits, including improved expansion dynamics and superior aesthetic results. Although previous investigators have evaluated its risks, few studies have assessed the impact of acellular dermal matrix on other outcomes, including patient-reported measures. Methods: The Mastectomy Reconstruction Outcomes Consortium Study used a prospective cohort design to evaluate patients undergoing postmastectomy reconstruction from 10 centers and 58 participating surgeons between 2012 and 2015. The analysis focused on women undergoing immediate tissue expander reconstruction following mastectomies for cancer treatment or prophylaxis. Medical records and patient-reported outcome data, using the BREAST-Q and Numeric Pain Rating Scale instruments, were reviewed. Bivariate analyses and mixed-effects regression models were applied. Results: A total of 1297 patients were evaluated, including 655 (50.5 percent) with acellular dermal matrix and 642 (49.5 percent) without acellular dermal matrix. Controlling for demographic and clinical covariates, no significant differences were seen between acellular dermal matrix and non–acellular dermal matrix cohorts in overall complications (OR, 1.21; p = 0.263), major complications (OR, 1.43; p = 0.052), wound infections (OR, 1.49; p = 0.118), or reconstructive failures (OR, 1.55; p = 0.089) at 2 years after reconstruction. There were also no significant differences between the cohorts in the time to expander/implant exchange (p = 0.78). No significant differences were observed in patient-reported outcome scores, including satisfaction with breasts, psychosocial well-being, sexual well-being, physical well-being, and postoperative pain. Conclusions: In this multicenter, prospective analysis, the authors found no significant acellular dermal matrix effects on complications, time to exchange, or patient-reported outcome in immediate expander/implant breast reconstruction. Further studies are needed to develop criteria for more selective use of acellular dermal matrix in these patients.

Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management

Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management


Perez J, Rohrich RJ
Plastic and Reconstructive Surgery: December 2017 - Volume 140 - Issue 6 - p 782e–793e

Background: Scar management is critical for every plastic surgeon’s practice and, ultimately, the patient’s satisfaction with his or her aesthetic result. Despite the critical nature of this component of routine postoperative care, there has yet to be a comprehensive analysis of the available literature over the past decade to assess the best algorithmic approach to scar care. To this end, a systematic review of best practices in preventative scar management was conducted to elucidate the highest level of evidence available on this subject to date. 
Methods: A computerized MEDLINE search was performed for clinical studies addressing scar management. The resulting publications were screened randomized clinical trials that met the authors’ specified inclusion/exclusion criteria. 
Results: This systematic review was performed in May of 2016. The initial search for the Medical Subject Headings term “cicatrix” and modifiers “therapy, radiotherapy, surgery, drug therapy, prevention, and control” yielded 13,101 initial articles. Applying the authors’ inclusion/exclusion criteria resulted in 12 relevant articles. All included articles are randomized, controlled, clinical trials. 
Conclusions: Optimal scar care requires taking into account factors such as incisional tension, anatomical location, and Fitzpatrick skin type. The authors present a streamlined algorithm for scar prophylaxis based on contemporary level I and II evidence to guide clinical practice.

[Review] Radiotherapy in the setting of breast reconstruction: types, techniques, and timing

[Review] Radiotherapy in the setting of breast reconstruction: types, techniques, and timing

Ho, AY et al

Lancet Oncology December 2017 Vol 18, 12 e742- e753

As the use of breast reconstruction and postmastectomy radiotherapy (PMRT) has increased over the past decade, the typical approach to integrating radiotherapy with breast reconstruction has provoked intense controversy in the management of breast cancer. PMRT can lead to an increased frequency of complications in the reconstructed breast. Conversely, the reconstructed breast can increase the complexity of radiotherapy delivery. How to minimise the frequency of complications without compromising oncological or cosmetic outcomes of the reconstructed breast is an important shared multidisciplinary goal for oncologists and their patients.

Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction

Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction

Manahan MA, et al

Plastic and Reconstructive Surgery:December 2017 - Volume 140 - Issue 6 - p 775e–781e

Summary: The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons’ Qualified Clinical Data Registry reporting, and national quality reporting programs.

The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery

The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery

Losken A et al

Plastic and Reconstructive Surgery: Durgery: January 2018 - Volume 141 - Issue 1 - p 10–19

Background: Autoaugmentation techniques have been applied to oncoplastic reductions to assist with filling larger, more remote defects, and to women with smaller breasts. The purpose of this report is to describe the use of autoaugmentation techniques in oncoplastic reduction and compare the results with those of traditional oncoplastic reduction. 
Methods: The authors queried a prospectively maintained database of all women who underwent partial mastectomy and oncoplastic reduction between 1994 and October of 2015. The autoaugmentation techniques were defined as (1) extended primary nipple autoaugmentation pedicle, and (2) primary nipple pedicle and secondary autoaugmentation pedicle. Comparisons were made to a control oncoplastic group. Results: There were a total of 333 patients, 222 patients (67.7 percent) without autoaugmentation and 111 patients (33 percent) with autoaugmentation (51 patients with an extended autoaugmentation pedicle, and 60 patients with a secondary autoaugmentation pedicle). Biopsy weight was smallest in the extended pedicle group (136 g) and largest in the regular oncoplastic group (235 g; p = 0.017). Superomedial was the most common extended pedicle, and lateral was the most common location. Inferolateral was the most common secondary pedicle for lateral and upper outer defects. There were no significant differences in the overall complication rate: 15.5 percent in the regular oncoplastic group, 19.6 percent in the extended pedicle group, and 20 percent in the secondary pedicle group. Conclusions: Autoaugmentation techniques have evolved to manage complex defects not amenable to standard oncoplastic reduction methods. They are often required for lateral defects, especially in smaller breasts. Autoaugmentation can be performed safely without an increased risk of complications, broadening the indications for breast conservation therapy. 

Two-Stage Prosthetic Breast Reconstruction: A Comparison Between Prepectoral and Partial Subpectoral Techniques

Two-Stage Prosthetic Breast Reconstruction: A Comparison Between Prepectoral and Partial Subpectoral Techniques

Nahabedian M Y, CocilovoC

Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6S - p 22S–30S

Background: Prosthetic breast reconstruction with prepectoral placement may confer clinical advantages compared with subpectoral placement. The purpose of this study was to assess and compare clinical outcomes following 2-stage reconstruction following prepectoral and partial subpectoral placement of tissue expanders and implants. Methods: A retrospective review of 39 (prepectoral) and 50 (partial subpectoral) patients was completed. Acellular dermal matrix was used in all patients. Mean age was 50.4 and 49.2 years, respectively. Body mass index (BMI) > 30 was noted in 15.4% of prepectoral and 18% of partial subpectoral patients. Radiation therapy was delivered to 38.5% of prepectoral patients and to 22% of partial subpectoral patients. Mean follow-up was 8.7 and 13 months for the prepectoral cohort and partial subpectoral cohorts. Results: The percentage of patients having at least 1 adverse event was 20.5% in the prepectoral and 22% in the partial subpectoral cohorts. The incidence of surgical-site infection and seroma was 8.1% and 4.8%, respectively, for the prepectoral cohort and 4.8% and 2.4%, respectively, for the partial subpectoral cohorts. Device explantation was 6.5% for the prepectoral and 7.2% for the partial subpectoral patients. Explantation did not occur in patients who had radiation or who had a BMI > 30. Four patients (6 breasts—7.2%) required conversion from partial subpectoral to prepectoral because of animation deformity. Conclusions: Prepectoral reconstruction is a viable alternative to partial subpectoral reconstruction. Proper patient selection is an important variable. Prepectoral reconstruction can be safely performed in patients with a BMI < 40 and in patients having postmastectomy radiation therapy.

Important Considerations for Performing Prepectoral Breast Reconstruction

Important Considerations for Performing Prepectoral Breast Reconstruction

Sbitany, H
Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6S - p 7S–13S

Summary: Prepectoral breast reconstruction has emerged as an excellent technique for postmastectomy reconstruction, as it allows for full preservation of a patient’s pectoralis major muscle and chest wall function. This reduces pain, eliminates animation deformity, and results in high patient satisfaction. Safely performed prepectoral breast reconstruction requires a careful patient selection process before committing to the procedure, taking into account comorbidities, radiation status, and oncologic criteria such as tumor location and breast cancer stage. Furthermore, a thorough intraoperative assessment of mastectomy skin flaps is critical, with careful and precise confirmation that the skin is viable and well perfused, prior to proceeding with prepectoral breast reconstruction. This can be done both clinically and with perfusion assessment devices. The use of acellular dermal matrix (ADM) has enhanced outcomes and aesthetics of prepectoral reconstruction, by providing implant coverage and soft-tissue support. The ADM also adds the benefit of reducing capsular contracture rates and offers full control over the aesthetic definition of the newly reconstructed breast pocket. Aesthetic enhancement of results requires routine use of oversizing implants in the skin envelope, careful selection of full capacity or cohesive gel implants, and autologous fat grafting. In this way, patients in all clinical scenarios can benefit from the full muscle-sparing technique of prepectoral breast reconstruction, including those undergoing immediate reconstruction, delayed reconstruction, and delayed conversion from a subpectoral to prepectoral plane to correct animation deformity.

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction

Weissler, J et al

Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6 - p 1110–1118

Background: As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Methods: In an effort to expand on Nahabedian’s 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. Results: The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. Conclusion: With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.

Sunday, 26 November 2017

Lower Extremity Free Flaps for Breast Reconstruction

Lower Extremity Free Flaps for Breast Reconstruction

Dayan, JH. Allen, RJ. 
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 77S–86S

Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient’s fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

Prepectoral Breast Reconstruction

Prepectoral Breast Reconstruction

Ter Louw, R P.  Nahabedian, M Y. 
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 51S–59S

Oncologic and reconstructive advancements in the management of patients with breast cancer and at high risk for breast cancer have led to improved outcomes and decreased patient morbidity. Traditional methods for prosthetic breast reconstructions have utilized total or partial muscle coverage of prosthetic devices. Although effective, placement of devices under the pectoralis major muscle can be associated with increased pain due to muscle spasm and animation deformities. Prepectoral prosthetic breast reconstruction has gained popularity in the plastic surgery community, and long-term outcomes have become available. This article will review the indications, technique, and current literature surrounding prepectoral prosthetic breast reconstruction.

Breast Reconstruction and Radiation Therapy: An Update

Breast Reconstruction and Radiation Therapy: An Update

Nelson, JA. Disa, JJ.
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 60S–68S

With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.