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.

Friday, 24 November 2017

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Katzel, EB.Bucky, LP. 

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 69S–76S

Summary: This article is a review of fat grafting for breast reconstruction. The use of small volume fat grafting for the correction of step-off deformities, intrinsic deformities, and extrinsic deformities of the breast, and the uses of large volume fat grafting for total breast reconstruction, correction of implant complications with simultaneous implant exchange with fat, and correction of noncancer chest wall deformities is reviewed. Cancer monitoring and the risks of cancer recurrence following fat-grafting to the breast is also reviewed.

Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Colwell, AS.Christensen, JM.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 7S–13S

Breast reconstruction following mastectomy has evolved to preserve the native skin and nipple of the breast and create a natural-appearing reconstruction in 1 or 2 surgeries. Nipple-sparing procedures appear to be oncologically safe with low risks of cancer recurrence. In our series of 2,182 nipple-sparing mastectomies, there was no development or recurrence of cancer in the nipple. Direct-to-implant single-stage surgery offers the patient a complete reconstruction at the time of mastectomy. Patient selection centers on preoperative breast anatomy combined with postoperative goals for size and uplift of the breast. The best candidates for nipple-sparing mastectomy and direct-to-implant breast reconstruction include those with grade I–II breast ptosis and those desiring to stay approximately the same breast size. The choice of incision and width of the implant play key roles in nipple centralization. Partial muscle coverage with acellular dermal matrix remains the most common technique to support the implant and offers the advantage of more soft-tissue coverage in the upper pole. With experience, complications and revisions are similar in this approach compared with more traditional 2-stage tissue expander-implant reconstruction. Thus, nipple-sparing mastectomy and direct-to-implant breast reconstruction is emerging as a preferred method of breast reconstruction when the breast skin envelope is sufficiently perfused.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Losken, A et al

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 14S–22S

The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Current Trends in Postmastectomy Breast Reconstruction

Current Trends in Postmastectomy Breast Reconstruction

Panchal, H. Matros, E.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 7S–13S

Postmastectomy immediate breast reconstruction in the U.S. continues to experience an upward trend owing to heightened awareness, innovations in reconstructive technique, growing evidence of improved patient-reported outcomes, and shifts in mastectomy patterns. Women with unilateral breast cancer are increasingly electing to undergo contralateral prophylactic mastectomy, instead of unilateral mastectomy or opting for breast conservation. The ascent in prophylactic surgeries correlates temporally to a shift toward prosthetic methods of reconstruction as the most common technique. Factors associated with the choice for implants include younger age, quicker recovery time, along with documented safety and enhanced aesthetic outcomes with newer generations of devices. Despite advances in autologous transfer, its growth is constrained by the greater technical expertise required to complete microsurgical transfer and potential barriers such as poor relative reimbursement. The increased use of radiation as an adjuvant treatment for management of breast cancer has created additional challenges for plastic surgeons who need to consider the optimal timing and method of breast reconstruction to perform in these patients.

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

Kim, J et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 30S–43S

Of the nearly 90,000 implant-based breast reconstructions performed in the United States, the majority use internal soft-tissue support. Aesthetically, these constructs may allow for better positioning of prosthesis, improve lower pole expansion, and increase projection. They may have particular utility in direct-to-implant, nipple-sparing mastectomies, and prepectoral reconstructions. In recent years, new permutations of acellular dermal matrices have evolved with diverse shapes, sizes, form-factor innovations, and processing characteristics. The literature is largely limited to retrospective studies (and meta-analyses thereof), making robust comparisons of 1 iteration vis-à-vis another difficult. Although synthetic mesh may provide a cost-effective alternative in primary and secondary reconstruction, comparative studies with acellular dermal matrix are lacking. This review aims to provide a balanced overview of recent biologic and synthetic mesh innovation. As this technology (and concomitant techniques) evolve, the reconstructive surgeon is afforded more—and better—choices to improve care for patients.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Lee, B et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5 - p 651e–664e

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient’s preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon’s technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Monday, 23 October 2017

Trends and predictions to 2020 in breast cancer mortality in Europe

Trends and predictions to 2020 in breast cancer mortality in Europe
Carioli G et al
The Breast, Article in Press

We analyzed trends in mortality from breast cancer in women in 36 European countries and the European Union (EU) over the period 1970–2014, and predicted numbers of deaths and rates to 2020.

Highlights:

  • EU breast cancer mortality rates declined by 15% between 2002 and 2012.
  • We predict a further 10% decline in breast cancer mortality to 2020.
  • The falls were largest in the young.
  • Trends were less favourable in central and eastern than in western Europe.
  • The key determinant of the falls is management; early diagnosis contributed, too.

Breast Cancer Genetics for Plastic Surgeons

Breast Cancer Genetics for Plastic Surgeons
McInerney, N et al

Plastic & Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 455–460

Summary: Multidisciplinary genetic clinics offer counseling and testing to those who meet criteria for familial breast cancer, and plastic surgeons become integral to this process when risk-reducing surgery and postmastectomy reconstruction are deemed appropriate. As reconstructive surgeons, it is important that plastic surgeons are aware of the risks and issues associated with the genetic variants that cause patients to present for prophylactic or therapeutic surgery.

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes

Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes
Cohen, O et al
Plastic and Reconstructive Surgery, September 2017 - Volume 140 - Issue 3 - p 382e–392e

Background: The increasing use of autologous fat grafting in breast cancer patients has raised concerns regarding its oncologic safety. This study evaluated patient outcomes and tumor recurrence following mastectomy reconstruction and autologous fat grafting. 
Methods: Retrospective chart review identified patients who underwent mastectomy followed by breast reconstruction from 2010 to 2015. Eight hundred twenty-nine breasts met inclusion criteria: 248 (30.0 percent) underwent autologous fat grafting, whereas 581 (70.0 percent) breasts did not. Patient demographics, cancer characteristics, oncologic treatment, surgical treatment, surgical complications, local recurrence, and distant metastases were analyzed. 
Results: Autologous fat grafting patients and control patients were of similar body mass index, smoking status, and BRCA status. Patients who underwent fat grafting were significantly younger than control patients and were less likely to have diabetes, hypertension, or hyperlipidemia. The two groups represented similar distributions of BRCA status, Oncotype scores, and hormone receptor status. Patients underwent one to four grafting procedures: one procedure in 83.1 percent, two procedures in 13.7 percent, three in 2.8 percent, and four in 0.4 percent. Mean follow-up time from initial surgery was 45.6 months in the fat grafting group and 38.8 months in controls. The overall complication rate following fat grafting was 9.4 percent. Among breasts undergoing surgery for therapeutic indications, there were similar rates of local recurrence (fat grafting group, 2.5 percent; controls, 1.9 percent; p = 0.747). Interestingly, mean time to recurrence was significantly longer in the fat grafting group (52.3 months versus 22.8 months from initial surgery; p = 0.016). 
Conclusions: Autologous fat grafting is a powerful tool in breast reconstruction. This large, single-institution study provides valuable evidence-based support for its oncologic safety. 

Five-Year Safety Data for More than 55,000 Subjects following Breast Implantation: Comparison of Rare Adverse Event Rates with Silicone Implants versus National Norms and Saline Implants

Five-Year Safety Data for More than 55,000 Subjects following Breast Implantation: Comparison of Rare Adverse Event Rates with Silicone Implants versus National Norms and Saline Implants
Singh, N et al
Plastic and  Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 666–679

Background: The U.S. Food and Drug Administration has required postapproval studies of silicone breast implants to evaluate the incidence of rare adverse events over 10 years after implantation. Methods: The Breast Implant Follow-Up Study is a large 10-year study (>1000 U.S. sites) evaluating long-term safety following primary augmentation, revision-augmentation, primary reconstruction, or revision-reconstruction with Natrelle round silicone breast implants compared with national norms and outcomes with saline implants. Targeted adverse events in subjects followed for 5 to 8 years included connective tissue diseases, neurologic diseases, cancer, and suicide. 
Results: The safety population comprised 55,279 women (primary augmentation, n = 42,873; revision-augmentation, n = 6837; primary reconstruction, n = 4828; and revision-reconstruction, n = 741). No targeted adverse events occurred at significantly greater rates in silicone implant groups versus national norms across all indications. The standardized incidence rate (observed/national norm) for all indications combined was 1.4 for cervical/vulvar cancer, 0.8 for brain cancer, 0.3 for multiple sclerosis, and 0.1 for lupus/lupus-like syndrome. Silicone implants did not significantly increase the risk for any targeted adverse events compared with saline implants. The risk of death was similar with silicone versus saline implants across all indications. The suicide rate (10.6 events per 100,000 person-years) was not significantly higher than the national norm. No implant-related deaths occurred. 
Conclusions: Results from 5 to 8 years of follow-up for a large number of subjects confirmed the safety of Natrelle round silicone implants, with no increased risk of systemic disease or suicide versus national norms or saline implants.

Breast Implant–Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand: High-Surface-Area Textured Implants Are Associated with Increased Risk

Breast Implant–Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand: High-Surface-Area Textured Implants Are Associated with Increased Risk
Loch-Wilkinson, A et al
Plastic and  Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 645–654


Background: The association between breast implants and breast implant–associated anaplastic large cell lymphoma (ALCL) has been confirmed. Implant-related risk has been difficult to estimate to date due to incomplete datasets. 
Methods: All cases in Australia and New Zealand were identified and analyzed. Textured implants reported in this group were subjected to surface area analysis. Sales data from three leading breast implant manufacturers (i.e., Mentor, Allergan, and Silimed) dating back to 1999 were secured to estimate implant-specific risk. 
Results: Fifty-five cases of breast implant–associated ALCL were diagnosed in Australia and New Zealand between 2007 and 2016. The mean age of patients was 47.1 years and the mean time of implant exposure was 7.46 years. There were four deaths in the series related to mass and/or metastatic presentation. All patients were exposed to textured implants. Surface area analysis confirmed that higher surface area was associated with 64 of the 75 implants used (85.3 percent). Biocell salt loss textured (Allergan, Inamed, and McGhan) implants accounted for 58.7 percent of the implants used in this series. Comparative analysis showed the risk of developing breast implant–associated ALCL to be 14.11 times higher with Biocell textured implants and 10.84 higher with polyurethane (Silimed) textured implants compared with Siltex textured implants. 
Conclusions: This study has calculated implant-specific risk of breast implant–associated ALCL. Higher-surface-area textured implants have been shown to significantly increase the risk of breast implant–associated ALCL in Australia and New Zealand. The authors present a unifying hypothesis to explain these observations.

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile

Mirzabeigi, M N et al
Plastic and Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 372e–381e


Background: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. 
Methods: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. 
Results: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. Conclusion: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.

Contralateral Prophylactic Mastectomy

Contralateral Prophylactic Mastectomy

Ramaswami R
New England Journal of Medicine, Volume 377, Issue 13, Page 1288-1291, September 2017.

CASE VIGNETTE
A Woman Considering Contralateral Prophylactic Mastectomy

A 51-year-old woman who has recently received a diagnosis of breast cancer, and she comes to you to seek your opinion about her surgical options. Three weeks earlier, she had undergone mammography and magnetic resonance imaging to evaluate a mass in the left breast. She has been told that she has a 3-cm triple-negative (i.e., negative for estrogen and progesterone receptors and for overexpression of human epidermal growth factor receptor type 2 [HER2]) invasive ductal carcinoma of the left breast. The breast cancer is at clinical stage IIA or T2N0M0 .......

Monday, 18 September 2017

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions
Merkkola-von Schantzet, P A al
The Breast October 2017 Volume 35, Pages 157–161

Contralateral reduction mammaplasty is regularly included in the treatment of breast cancer patients. We analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens of women with previous breast cancer. We also analyzed if timing of reduction mammaplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics.

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire
Mylvaganam S et al
The Breast October 2017Volume 35, Pages 182–190

The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.

Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer

Prognostic assessment and systemic treatments of invasive local relapses of hormone receptor-positive breast cancer
Zingarello A et al
The Breast October 2017 Volume 35, Pages 162–168

The rate of local recurrences, after breast-conserving surgery or mastectomy for hormone receptor-positive (HR+) breast cancer, has dramatically changed in last decades, due to advances in surgical and radiation techniques and a more extensive use of adjuvant systemic treatments. However, the occurrence of local recurrences remains a major predictor for distant metastasis and is responsible for increased cancer-specific death. It has been estimated that 1 in 4 HR+ and HR-ipsilateral breast recurrences leads to widespread metastatic disease, with an annual mortality rate of 10% in the first 5 years.

Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review

Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review
Toss M et al
The Breast October 2017 Volume 35, Pages 151–156

The high proportion of ductal carcinoma in situ (DCIS) presented in mammographic screening and the relatively low risk of progression to invasive disease have raised questions related to overtreatment. Following a review of current DCIS management protocols a more conservative approach has been suggested. Clinical trials have been introduced to evaluate the option of avoiding surgical intervention in a proportion of patients with DCIS defined as “low-risk” using certain clinicopathological criteria.