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Aesthetic Surgery Journal Jun 2021There is limited evidence available in the literature with regard to the complication profile of mastectomy and immediate prosthetic reconstruction in augmented patients. (Meta-Analysis)
Meta-Analysis
BACKGROUND
There is limited evidence available in the literature with regard to the complication profile of mastectomy and immediate prosthetic reconstruction in augmented patients.
OBJECTIVES
The aim of this systematic review and meta-analysis was to compare postoperative complications between women with vs without prior augmentation undergoing skin- or nipple-sparing mastectomy and immediate prosthetic reconstruction.
METHODS
A systematic search was conducted in February 2020 for studies comparing women with vs without prior augmentation undergoing skin- or nipple-sparing mastectomy and immediate prosthetic reconstruction with documentation of postoperative complications. Outcomes analyzed included early, late, and overall complications. Pooled odds ratios (ORs) with 95% CIs were obtained through meta-analysis.
RESULTS
Our meta-analysis, which included 6 studies comparing 241 breasts with prior augmentation and 1441 without, demonstrated no significant difference between the 2 groups in rates of early (36.7% vs 24.8%: OR, 1.57; 95% CI, 0.94-2.64; P = 0.09), late (10.1% vs 19.9%: OR, 0.53; 95% CI, 0.06-4.89; P = 0.57), and overall complications (36.5% vs 31.2%: OR, 1.23; 95% CI, 0.76-2.00; P = 0.40). Subgroup analysis showed a significantly higher rate of hematoma formation in the augmented group (3.39% vs 2.15%: OR, 2.68; 95% CI, 1.00-7.16; P = 0.05), but no difference in rates of seroma, infection, mastectomy skin flap necrosis, and prosthesis loss.
CONCLUSIONS
Our meta-analysis suggests that prior augmentation does not significantly increase overall postoperative complications in women undergoing skin- or nipple-sparing mastectomy and immediate prosthetic reconstruction. However, the significantly higher rate of hematoma formation in augmented patients warrants further investigation and preoperative discussion.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Mastectomy, Subcutaneous; Nipples; Postoperative Complications; Retrospective Studies; Seroma
PubMed: 33480970
DOI: 10.1093/asj/sjab028 -
Breast Cancer (Dove Medical Press) 2016Mastectomy and breast-conserving surgery (BCS) are important treatment options for breast cancer patients. A previous meta-analysis demonstrated that the risk of certain... (Review)
Review
A systematic review and meta-analysis of Harmonic technology compared with conventional techniques in mastectomy and breast-conserving surgery with lymphadenectomy for breast cancer.
BACKGROUND
Mastectomy and breast-conserving surgery (BCS) are important treatment options for breast cancer patients. A previous meta-analysis demonstrated that the risk of certain complications can be reduced with the Harmonic technology compared with conventional methods in mastectomy. However, the meta-analysis did not include studies of BCS patients and focused on a subset of surgical complications. The objective of this study was to compare Harmonic technology and conventional techniques for a range of clinical outcomes and complications in both mastectomy and BCS patients, including axillary lymph node dissection.
METHODS
A comprehensive literature search was performed for randomized controlled trials comparing Harmonic technology and conventional methods in breast cancer surgery. Outcome measures included blood loss, drainage volume, total complications, seroma, necrosis, wound infections, ecchymosis, hematoma, hospital length of stay, and operating time. Risk of bias was analyzed for all studies. Meta-analysis was performed using random-effects models for mean differences of continuous variables and a fixed-effects model for risk ratios of dichotomous variables.
RESULTS
Twelve studies met the inclusion criteria. Across surgery types, compared to conventional techniques, Harmonic technology reduced total complications by 52% (P=0.002), seroma by 46% (P<0.0001), necrosis by 49% (P=0.04), postoperative chest wall drainage by 46% (P=0.0005), blood loss by 38% (P=0.0005), and length of stay by 22% (P=0.007). Although benefits generally appeared greatest in mastectomy patients with lymph node dissection, Harmonic technology showed significant reductions in complications in the BCS study subgroup.
CONCLUSION
In this meta-analysis of both mastectomy and BCS procedures, the use of Harmonic technology reduced the risk of most complications by about half across breast cancer surgery patients. These benefits may be due to superior hemostatic capabilities of Harmonic technology and better dissection, particularly lymph node dissection. Reduction in complications and other resource outcomes may engender lower downstream health care costs.
PubMed: 27486342
DOI: 10.2147/BCTT.S110461 -
Aesthetic Plastic Surgery Feb 2023Gestational gigantomastia (GG) is an uncommon pregnancy condition, and the underlying cause of GG has yet to be determined. Medical management and surgery are two... (Review)
Review
BACKGROUND
Gestational gigantomastia (GG) is an uncommon pregnancy condition, and the underlying cause of GG has yet to be determined. Medical management and surgery are two treatment options for GG, and breast reduction or mastectomy with delayed reconstruction is the only available surgical option. We have conducted this systematic review to summarize and critically analyze all the GG data in the literature.
METHODS
The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines were adhered to in reporting this article. A systematic search was conducted in February 2022 for published case reports and case series on GG using the PubMed, MEDLINE, and Cochrane databases. The following keywords were used: macromastia, gestational gigantomastia, and gestational.
RESULTS
A total of 639 articles were searched, and only 66 case reports published between 1962 and 2022 were included. The mean patient's age at presentation was 28.79 years old. The majority of the patients were in their first trimester (n = 23, 47%). The main complaint was rapid bilateral breast enlargement (n = 54, 80.59%). Bromocriptine was the most common medical management used (n = 19/35, 54.28%). Bilateral breast reduction was the most common surgery (n = 24/48, 50%). Most patients had uneventful recovery (n = 40/54, 74.07%).
CONCLUSION
Gigantomastia is a difficult condition, in terms of its management. We have found that surgery is the gold-standard among all the cases reported; while Bromocriptine was the most commonly administered medical therapy. This systematic review provides a guideline for plastic surgeons to better facilitate their care of these patients.
LEVEL OF EVIDENCE III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Topics: Female; Pregnancy; Humans; Adult; Mastectomy; Bromocriptine; Breast Neoplasms; Treatment Outcome; Mammaplasty
PubMed: 35941388
DOI: 10.1007/s00266-022-03003-5 -
Plastic and Reconstructive Surgery May 2022Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a...
BACKGROUND
Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a standardized definition for it has led to variation in estimated incidence, from as low as 2 percent to greater than 40 percent. The authors systematically reviewed the literature on mastectomy skin flap necrosis to characterize existing definitions and provide a framework for future classification.
METHODS
A systematic review of the PubMed and Cochrane databases identified studies reporting a discrete definition of mastectomy skin flap necrosis and corresponding outcomes in breast reconstruction. Provided definitions were extracted, categorized, and comparatively analyzed.
RESULTS
Fifty-nine studies met inclusion criteria, with a combined total of 14,368 patients and 18,920 breasts. Thirty-four studies (57.6 percent) reported mastectomy skin flap necrosis solely as a function of total breasts, and 11 (18.6 percent) reported mastectomy skin flap necrosis solely as a function of total patients. Only 14 studies (23.7 percent) provided two separate rates. The overall rate of mastectomy skin flap necrosis was 10.4 percent (range, 2.3 to 41.2 percent) and 15.3 percent (range, 4.7 to 39.0 percent), when reported per breast or per patient, respectively. Studies were categorized by mastectomy skin flap necrosis definition, including intervention (n = 33), depth (n = 20), area (n = 4), and timing (n = 2). Mastectomy skin flap necrosis rates were highest in studies defining necrosis by depth (15.1 percent), followed by intervention (9.6 percent), timing (6.4 percent), and area (6.3 percent). Necrosis rates among studies defining mastectomy skin flap necrosis by intervention, depth, and area were found to be statistically different (p < 0.001).
CONCLUSIONS
Reported mastectomy skin flap necrosis definitions and outcomes vary significantly in the existing literature. For accurate characterization and quantification, a clear, simplified, consensus definition must be adopted.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Necrosis; Postoperative Complications; Reference Standards; Retrospective Studies; Surgical Flaps
PubMed: 35245258
DOI: 10.1097/PRS.0000000000008983 -
Breast Cancer (Dove Medical Press) 2021The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire's ability to reflect patient-reported outcomes in women who have... (Review)
Review
PURPOSE
The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire's ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy.
METHODS
PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included.
RESULTS
A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including 'satisfaction with breasts', "satisfaction with outcome" "psychosocial", "physical", and "sexual wellbeing". Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8-80.0 and 39.0-78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively.
CONCLUSION
This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.
PubMed: 34938118
DOI: 10.2147/BCTT.S256393 -
European Journal of Surgical Oncology :... May 2016Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. The purpose was to assess the available evidence on uptake,... (Review)
Review
PURPOSE
Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. The purpose was to assess the available evidence on uptake, outcome and quality of life (QoL) after BR in older women.
METHODS
A systematic literature review was performed via Medline, Embase and Cochrane databases using the search terms breast reconstruction, breast cancer, and mastectomy. Eligible studies reported rates of BR, rates of different reconstructive techniques, complication rates, and/or patient reported outcome measures (PROMs) of BR in women aged 60 years or older undergoing mastectomy for ductal carcinoma in situ or invasive carcinoma.
RESULTS
A total of 42 eligible studies were included, with 32 of these reporting BR rates, 10 reporting rates of different reconstructive techniques, 10 reporting rates of complications, and four reporting PROMs. The studies reported 24,746 cases of BR in 407,570 mastectomy patients aged 60 years or older from 1987 to 2012. Implant based BR was more common than autologous techniques. Mostly, complication rates were not higher in older women, and QoL outcomes were similar to younger women.
CONCLUSIONS
This review confirms that BR rates are lower in older women despite recent studies demonstrating its efficacy. The perception among some surgeons and women requiring mastectomy that the potential risks of BR in older women outweigh the benefits needs to be revisited. Education of consumers and surgeons along with public advocacy for offering BR to all clinically eligible women are the most promising means of changing practice.
Topics: Aged; Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Middle Aged; Outcome Assessment, Health Care; Postoperative Complications; Quality of Life
PubMed: 26965305
DOI: 10.1016/j.ejso.2016.02.010 -
Annali Italiani Di Chirurgia 2016Oncoplastic breast-conserving surgery (OPBS) is a rapidly emerging field. Various oncoplastic techniques have been proposed and are increasingly adopted to facilitate... (Review)
Review
BACKGROUND
Oncoplastic breast-conserving surgery (OPBS) is a rapidly emerging field. Various oncoplastic techniques have been proposed and are increasingly adopted to facilitate breast conservation and preserve breast aesthetics. This systematic review seeks to assess the oncological and cosmetic outcomes of OPBS.
MATERIALS AND METHODS
A systematic review of the literature was conducted using specific inclusion and exclusion criteria, for articles published up to July 31th, 2015. Relevant studies were identified using computerized bibliographic searches of MEDLINE database. The keywords that were used in various combinations were: "Oncoplastic surgery", "oncological results", "cosmetic results", "cosmesis", "immediate reconstruction" and "breast conserving surgery".
RESULTS
A total of 106 articles were identified for potential inclusion and reviewed in detail. No randomized controlled trials were identified. This study was initially designed to identify and review after a strict selection process, published articles with the highest level of evidence on OPBS. Systematic reviews and metanalyses were not included in this systematic review for methodological reasons. Ten prospective studies fulfilled strict inclusion criteria and were included. Local relapse using OPBS did not exceed 7%. Tumor free margins were retrieved in 86% of cases. Good cosmetic results were obtained in 86% of patients. Most studies showed significant weaknesses, including absence of robust design and methodological limitations, influencing negatively generalizability.
CONCLUSIONS
This systematic review proves that current evidence supporting efficacy of OPBS in based on poorly designed and underpowered studies. Further studies and particularly RCTs, are required to assess oncological safety and cosmetic results of OPBS, reporting evidence on long-term oncological results, cosmetic outcomes and survival rates of patients treated with this technique.
KEY WORDS
Oncoplastic surgery, Oncological results, Cosmetic results, Cosmesis, Immediate reconstruction, Breast conserving surgery.
Topics: Breast Neoplasms; Female; Humans; Mastectomy, Segmental; Treatment Outcome
PubMed: 27346470
DOI: No ID Found -
Cancer Oct 2022Oncological safety of different types and timings of PMBR after breast cancer remains controversial. Lack of stratified risk assessment in literature makes current... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Oncological safety of different types and timings of PMBR after breast cancer remains controversial. Lack of stratified risk assessment in literature makes current clinical and shared decision-making complex. This is the first systematic review and meta-analysis to evaluate differences in oncological outcomes after immediate versus delayed postmastectomy breast reconstruction (PMBR) for autologous and implant-based PMBR separately.
METHODS
A systematic literature search was performed in MEDLINE, Cochrane Library, and Embase. The Cochrane Collaboration Handbook and Meta-analysis Of Observational Studies in Epidemiology checklist were followed for data abstraction. Variability in point estimates attributable to heterogeneity was assessed using I -statistic. (Loco)regional breast cancer recurrence rates, distant metastasis rates, and overall breast cancer recurrence rates were pooled in generalized linear mixed models using random effects.
RESULTS
Fifty-five studies, evaluating 14,217 patients, were included. When comparing immediate versus delayed autologous PMBR, weighted average proportions were: 0.03 (95% confidence interval [CI], 0.02-0.03) versus 0.02 (95% CI, 0.01-0.04), respectively, for local recurrences, 0.02 (95% CI, 0.01-0.03) versus 0.02 (95% CI, 0.01-0.03) for regional recurrences, and 0.04 (95% CI, 0.03-0.06) versus 0.01 (95% CI, 0.00-0.03) for locoregional recurrences. No statistically significant differences in weighted average proportions for local, regional and locoregional recurrence rates were observed between immediate and delayed autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrences after autologous PMBR, and of all outcome measures after implant-based PMBR.
CONCLUSIONS
Delayed autologous PMBR leads to similar (loco)regional breast cancer recurrence rates compared to immediate autologous PMBR. This study highlights the paucity of strong evidence on breast cancer recurrence after specific types and timings of PMBR.
LAY SUMMERY
Oncologic safety of different types and timings of postmastectomy breast reconstruction (PMBR) remains controversial. Lack of stratified risk assessment in literature makes clinical and shared decision-making complex. This meta-analysis showed that delayed autologous PMBR leads to similar (loco)regional recurrence rates as immediate autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrence after autologous PMBR, and of all outcome measures after implant-based PMBR. Based on current evidence, oncological concerns do not seem a valid reason to withhold patients from certain reconstructive timings or techniques, and patients should equally be offered all reconstructive options they technically qualify for.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Neoplasm Recurrence, Local; Transplantation, Autologous
PubMed: 35894936
DOI: 10.1002/cncr.34393 -
Plastic and Reconstructive Surgery Aug 2022Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex.
METHODS
The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis. The authors searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/nipple-areola complex or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence estimates of nerve branches supplying the nipple/nipple-areola complex were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance checklist.
RESULTS
Of 3653 studies identified, 19 were eligible for qualitative synthesis and seven for meta-analysis. The breast skin is innervated by anterior cutaneous branches and lateral cutaneous branches of the second through sixth and the nipple/nipple-areola complex primarily by anterior cutaneous branches and lateral cutaneous branches of the third through fifth intercostal nerves. The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve supply the largest surface area of the breast skin and nipple/nipple-areola complex. The lateral cutaneous branch of the fourth intercostal nerve is the most consistent contributory nerve to the nipple/nipple-areola complex (pooled prevalence, 89.0 percent; 95 percent CI, 0.80 to 0.94).
CONCLUSIONS
The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.
Topics: Biological Phenomena; Breast; Dissection; Female; Humans; Intercostal Nerves; Mammaplasty; Mastectomy; Nipples
PubMed: 35652898
DOI: 10.1097/PRS.0000000000009306 -
The Cochrane Database of Systematic... Jun 2023Continual improvement in adjuvant therapies has resulted in a better prognosis for women diagnosed with breast cancer. A surrogate marker used to detect the spread of... (Review)
Review
BACKGROUND
Continual improvement in adjuvant therapies has resulted in a better prognosis for women diagnosed with breast cancer. A surrogate marker used to detect the spread of disease after treatment of breast cancer is local and regional recurrence. The risk of local and regional recurrence after mastectomy increases with the number of axillary lymph nodes affected by cancer. There is a consensus to use radiotherapy as an adjuvant treatment after mastectomy (postmastectomy radiotherapy (PMRT)) in women diagnosed with breast cancer and found to have disease in four or more positive axillary lymph nodes. Despite data showing almost double the risk of local and regional recurrence in women treated with mastectomy and found to have one to three positive lymph nodes, there is a lack of international consensus on the use of PMRT in this group.
OBJECTIVES
To assess the effects of PMRT in women diagnosed with early breast cancer and found to have one to three positive axillary lymph nodes.
SEARCH METHODS
We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov up to 24 September 2021.
SELECTION CRITERIA
We included randomised controlled trials (RCTs). The inclusion criteria included women diagnosed with breast cancer treated with simple or modified radical mastectomy and axillary surgery (sentinel lymph node biopsy (SLNB) alone or those undergoing axillary lymph node clearance with or without prior SLNB). We included only women receiving PMRT using X-rays (electron and photon radiation), and we defined the radiotherapy dose to reflect what is currently being recommended (i.e. 40 Gray (Gy) to 50 Gy in 15 to 25/28 fractions in 3 to 5 weeks. The included studies did not administer any boost to the tumour bed. In this review, we excluded studies using neoadjuvant chemotherapy as a supportive treatment before surgery.
DATA COLLECTION AND ANALYSIS
We used Covidence to screen records. We collected data on tumour characteristics, adjuvant treatments and the outcomes of local and regional recurrence, overall survival, disease-free survival, time to progression, short- and long-term adverse events and quality of life. We reported on time-to-event outcome measures using the hazard ratio (HR) and subdistribution HR. We used Cochrane's risk of bias tool (RoB 1), and we presented overall certainty of the evidence using the GRADE approach.
MAIN RESULTS
The RCTs included in this review were subgroup analyses of original RCTs conducted in the 1980s to assess the effectiveness of PMRT. Hence, the type and duration of adjuvant systemic treatments used in the studies included in this review were suboptimal compared to the current standard of care. The review involved three RCTs with a total of 829 women diagnosed with breast cancer and low-volume axillary disease. Amongst the included studies, only a single study pertained to the modern-day radiotherapy practice. The results from this one study showed a reduction of local and regional recurrence (HR 0.20, 95% confidence interval (CI) 0.13 to 0.33, 1 study, 522 women; low-certainty evidence) and improvement in overall survival with PMRT (HR 0.76, 95% CI 0.60 to 0.97, 1 study, 522 women; moderate-certainty evidence). One of the other studies using radiotherapy techniques that do not reflect modern-day practice reported on disease-free survival in women with low-volume axillary disease (subdistribution HR 0.63, 95% CI 0.41 to 0.96, 1 study, 173 women). None of the included studies reported on PMRT side effects or quality-of-life outcome measures.
AUTHORS' CONCLUSIONS
Based on one study, the use of PMRT in women diagnosed with breast cancer and low-volume axillary disease indicated a reduction in locoregional recurrence and an improvement in survival. There is a need for more research to be conducted using modern-day radiotherapy equipment and methods to support and supplement the review findings.
Topics: Female; Humans; Neoplasm Recurrence, Local; Breast Neoplasms; Combined Modality Therapy; Mastectomy; Lymph Nodes
PubMed: 37327075
DOI: 10.1002/14651858.CD014463.pub2