-
Aesthetic Surgery Journal Nov 2020The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical...
The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.
Topics: Breast Neoplasms; Esthetics; Humans; Mammaplasty; Mastectomy; Mastectomy, Subcutaneous; Nipples
PubMed: 33202011
DOI: 10.1093/asj/sjaa130 -
Transactions of the American Clinical... 2016We studied women after breast-conserving surgery and mastectomy with immediate (IR) and delayed reconstruction to determine the risk of surgical site infections (SSIs)....
We studied women after breast-conserving surgery and mastectomy with immediate (IR) and delayed reconstruction to determine the risk of surgical site infections (SSIs). The SSI rate was 1.3% for BCS, 5.2% for mastectomy, and 10.3% for mastectomy plus IR with flap. SSI risk was higher for mastectomy and IR with implantation versus delayed reconstruction with implantation (8.8% versus 5.9%, = 0.039) or staged reconstruction with implantation (3.3%, <0.001). Women with SSI had more SSIs after second-staged reconstruction and implantation compared to those without SSI (10.9% versus 2.7%, <0.001). SSI was first coded 2 to 30 days postoperatively in 50.3%, and 23% between 31 and 60 days postoperatively. The noninfectious wound complication rate was 10.8%. The noninfectious wound complication rate was 5.8% after mastectomy, 13.4% after mastectomy with implantation, 18.7% after mastectomy with flap, and 15.2% with mastectomy flap and implantation ( <0.001). Implants were removed within 60 days in 6% of mastectomies with implantation.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Organ Sparing Treatments; Retrospective Studies; Risk Factors; Surgical Flaps; Surgical Wound Infection; Treatment Outcome
PubMed: 28066037
DOI: No ID Found -
Breast (Edinburgh, Scotland) Jun 2023Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients'... (Review)
Review
Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Mastectomy, Segmental; Artificial Intelligence; Breast; Mammaplasty
PubMed: 36924556
DOI: 10.1016/j.breast.2023.03.006 -
Einstein (Sao Paulo, Brazil) 2020Angiosarcoma of the breast accounts for less than 1% of breast tumors. This tumor may be primary or secondary to previous radiation therapy and it is also named...
Angiosarcoma of the breast accounts for less than 1% of breast tumors. This tumor may be primary or secondary to previous radiation therapy and it is also named "radiogenic angiosarcoma of the breast", which is still a rare entity with a poor prognosis. So far, there are only 307 cases reported about these tumors in the literature. We present a case of a 73-year-old woman with a prior history of breast-conserving treatment of right breast cancer, exhibiting mild pinkish skin changes in the ipsilateral breast. Her mammography was consistent with benign alterations (BI-RADS 2). On incisional biopsy specimens, hematoxylin-eosin showed atypical vascular lesion and suggested immunohistochemisty for diagnostic elucidation. Resection of the lesions was performed and histology showed radiogenic angiosarcoma. The patient underwent simple mastectomy. Immunohistochemistry was positive for antigens related to CD31 and CD34, and C-MYC oncogene amplification, confirming the diagnosis of angiosarcoma induced by breast irradiation. A delayed diagnosis is an important concern. Initial skin changes in radiogenic angiosarcoma are subtle, therefore, these alterations may be confused with other benign skin conditions such as telangiectasia. We highlight this case clinical aspects with the intention of alerting to the possibility of angiosarcoma of the breast in patients with a previous history of adjuvant radiation therapy for breast cancer treatment. Sixteen months after the surgery the patient remains asymptomatic.
Topics: Aged; Breast; Breast Neoplasms; Female; Hemangiosarcoma; Humans; Mastectomy; Neoplasms, Radiation-Induced
PubMed: 33295433
DOI: 10.31744/einstein_journal/2020RC5439 -
European Journal of Surgical Oncology :... Jul 2016Skin-sparing mastectomy (SSM) facilitates immediate breast reconstruction. We investigated locoregional recurrence rates after SSM compared with simple mastectomy and...
UNLABELLED
Skin-sparing mastectomy (SSM) facilitates immediate breast reconstruction. We investigated locoregional recurrence rates after SSM compared with simple mastectomy and the factors predicting oncological failure.
METHODS
Patients with early breast cancer that underwent mastectomy between 2000 and 2005 at a single institution were studied to ascertain local and systemic recurrence rates between groups. Kaplan-Meier curves and log-rank test were used to evaluate disease-free survival.
RESULTS
Patients (n = 577) underwent simple mastectomy (80%) or SSM (20%). Median follow up was 80 months. Patients undergoing SSM were of younger average age, less often had involved lymph nodes (22% vs 44%, p < 0.001), more often had DCIS present (79% vs 53%, p < 0.001) and involved margins (29% vs 15%, p = 0.001). Involved surgical margins were associated with large size (p = 0.001). The 8-year local recurrence (LR) rates were 7.9% for SSM and 5% for simple mastectomy respectively (p = 0.35). Predictors of locoregional recurrence were lymph node involvement (HR 8.0, for >4 nodes, p < 0.001) and involved surgical margins (HR 3.3, p = 0.002). In node negative patients, SSM was a predictor of locoregional recurrence (HR 4.8 [1.1, 19.9], p = 0.033).
CONCLUSION(S)
Delayed reconstruction is more appropriate for node positive early breast cancer after post-mastectomy radiotherapy. Re-excision of involved margins is essential to prevent local recurrence after mastectomy.
Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Chemotherapy, Adjuvant; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Margins of Excision; Mastectomy, Simple; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Organ Sparing Treatments; Predictive Value of Tests; Radiotherapy, Adjuvant; Retrospective Studies; Risk Factors; Skin
PubMed: 27256869
DOI: 10.1016/j.ejso.2016.04.055 -
Plastic and Reconstructive Surgery Feb 2023Preoperative vascular mapping has been demonstrated to be an excellent adjunct to perforator flap surgery by reducing operative times and enhancing surgical precision....
BACKGROUND
Preoperative vascular mapping has been demonstrated to be an excellent adjunct to perforator flap surgery by reducing operative times and enhancing surgical precision. This study evaluated the benefit of preoperative vascular mapping using magnetic resonance imaging and Doppler ultrasonography to identify the different perforators to the breast and compared it to postoperative mapping. The authors' intent was to determine whether preoperative knowledge of the various vascular sources to the nipple-areola complex affected the outcome and vitality of the nipple-areola complex.
METHODS
A prospective study was performed on 15 patients undergoing 25 nipple-sparing mastectomies for breast cancer or genetic predisposition. Ten patients underwent bilateral mastectomy, and five underwent unilateral mastectomy. Mean age was 52 years (range, 30 to 76 years). The mean patient body mass index was 22.4 kg/m2 (range, 20 to 35 kg/m2). Inclusion criteria consisted of breast cancer or genetic predisposition and grade 1 or 2 breast ptosis. Exclusion criteria included prior breast surgery, grade 3 ptosis, and gigantomastia. All patients underwent immediate direct-to-implant reconstruction.
RESULTS
Preoperative vascular mapping by magnetic resonance imaging and external Doppler ultrasonography was performed in all 15 patients. In all 25 breasts, the fifth anterior intercostal artery perforator was identified preoperatively and preserved intraoperatively. Postoperative imaging demonstrated patency of the fifth anterior intercostal artery perforator vessels in all patients. Nipple-areola viability was demonstrated in all breasts.
CONCLUSIONS
This study demonstrates that preoperative magnetic resonance imaging and Doppler ultrasonography for mapping breast perforator vessels is a useful strategy and should be considered for select patients undergoing nipple-sparing mastectomy. Identification of dominant perforators to the breast allowed mastectomy planning with preservation of the important perforator to the mastectomy skin flaps and nipple-areola complex.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, IV.
Topics: Humans; Middle Aged; Female; Nipples; Mastectomy; Breast Neoplasms; Prospective Studies; Genetic Predisposition to Disease; Mastectomy, Subcutaneous; Perforator Flap; Mammaplasty; Retrospective Studies
PubMed: 36696303
DOI: 10.1097/PRS.0000000000009824 -
Plastic and Reconstructive Surgery Oct 2022No meta-analysis has examined whether contralateral prophylactic mastectomy increases complication risk for unilateral breast cancer patients undergoing unilateral... (Meta-Analysis)
Meta-Analysis
BACKGROUND
No meta-analysis has examined whether contralateral prophylactic mastectomy increases complication risk for unilateral breast cancer patients undergoing unilateral mastectomy.
METHODS
Fifteen studies on complications of unilateral mastectomy plus contralateral prophylactic mastectomy met inclusion criteria. Meta-analyses compared complications of (1) diseased versus contralateral breasts in unilateral plus contralateral prophylactic mastectomy patients and (2) patients undergoing unilateral plus contralateral prophylactic mastectomy versus unilateral alone when grouped by reconstructive method.
RESULTS
For all unilateral plus contralateral prophylactic mastectomy patients, the diseased breast was significantly more prone to complications versus the contralateral breast (relative risk, 1.24; p = 0.03). In studies that stratified by reconstructive method, the complication risk was significantly higher for unilateral plus contralateral prophylactic mastectomy versus unilateral mastectomy alone for patients with no reconstruction (relative risk, 2.03; p = 0.0003), prosthetic-based reconstruction (relative risk,1.42; p = 0.003), and autologous reconstruction (relative risk, 1.32; p = 0.005). The only prospective trial showed similar results, including for more severe complications. Smaller retrospective studies without stratification by reconstructive method showed similar complications for unilateral plus contralateral prophylactic mastectomy versus unilateral mastectomy alone (relative risk, 1.06; p = 0.70). These groups had similar incidences of complication-related delay in adjuvant therapy, as demonstrated by one study.
CONCLUSIONS
After unilateral plus contralateral prophylactic mastectomy, diseased breasts are at higher risk for complications. Stronger evidence supports higher complication risk for unilateral plus contralateral prophylactic mastectomy than unilateral alone. More work is needed to determine the effect of complications on timing of adjuvant therapy.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Prophylactic Mastectomy; Prospective Studies; Retrospective Studies
PubMed: 35943952
DOI: 10.1097/PRS.0000000000009493 -
Surgery Today Jun 2021Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a... (Comparative Study)
Comparative Study Review
Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a surgical-management paradigm change toward less-aggressive surgery that combines the use of breast-conserving or -reconstruction therapy as a new standard of care with a higher emphasis on cosmesis. The implementation of skin-sparing and nipple-sparing mastectomies (SSM, NSM) has been shown to be oncologically safe, and breast reconstructive surgery is being performed increasingly for patients with breast cancer. NSM and breast reconstruction can also be performed as prophylactic or risk-reduction surgery for women with BRCA gene mutations. Compared with conventional breast construction followed by total mastectomy (TM), NSM preserving the nipple-areolar complex (NAC) with breast reconstruction provides psychosocial and aesthetic benefits, thereby improving patients' cosmetic appearance and body image. Implant-based breast reconstruction (IBBR) has been used worldwide following mastectomy as a safe and cost-effective method of breast reconstruction. We review the clinical evidence about immediate (one-stage) and delayed (two-stage) IBBR after NSM. Our results suggest that the postoperative complication rate may be higher after NSM followed by IBBR than after TM or SSM followed by IBBR.
Topics: Adult; Aged; Breast Implantation; Breast Implants; Breast Neoplasms; Combined Modality Therapy; Cost-Benefit Analysis; Female; Humans; Mammaplasty; Mastectomy, Segmental; Middle Aged; Mutation; Nipples; Organ Sparing Treatments; Prophylactic Mastectomy; Safety; Treatment Outcome; Ubiquitin-Protein Ligases
PubMed: 33185799
DOI: 10.1007/s00595-020-02175-4 -
JAMA Surgery Aug 2022Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and... (Observational Study)
Observational Study
IMPORTANCE
Rates of lumpectomy for breast cancer management in the United States previously declined in favor of more aggressive surgical options, such as mastectomy and contralateral prophylactic mastectomy (CPM).
OBJECTIVE
To evaluate longitudinal trends in the rates of lumpectomy and mastectomy, including unilateral mastectomy vs CPM rates, and to determine characteristics associated with current surgical practice using 3 national data sets.
DESIGN AND SETTING
Data from the National Surgical Quality Improvement Program (NSQIP), Surveillance, Epidemiology, and End Results (SEER) program, and National Cancer Database (NCDB) were examined to evaluate trends in lumpectomy and mastectomy rates from 2005 through 2017. Mastectomy rates were also evaluated with a focus on CPM. Longitudinal trends were analyzed using the Cochran-Armitage test for trend. Multivariate logistic regression models were performed on the NCDB data set to identify predictors of lumpectomy and CPM.
RESULTS
A study sample of 3 467 645 female surgical breast cancer patients was analyzed. Lumpectomy rates reached a nadir between 2010 and 2013, with a significant increase thereafter. Conversely, in comparison with lumpectomy rates, overall mastectomy rates declined significantly starting in 2013. Cochran-Armitage trend tests demonstrated an annual decrease in lumpectomy rates of 1.31% (95% CI, 1.30%-1.32%), 0.07% (95% CI, 0.01%-0.12%), and 0.15% (95% CI, 0.15%-0.16%) for NSQIP, SEER, and NCDB, respectively, from 2005 to 2013 (P < .001, P = .01, and P < .001, respectively). From 2013 to 2017, the annual increase in lumpectomy rates was 0.96% (95% CI, 0.95%-0.98%), 1.60% (95% CI, 1.59%-1.62%), and 1.66% (95% CI, 1.65%-1.67%) for NSQIP, SEER, and NCDB, respectively (all P < .001). Comparisons of specific mastectomy types showed that unilateral mastectomy and CPM rates stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM rates throughout the entire time period.
CONCLUSIONS
This observational longitudinal analysis indicated a trend reversal with an increase in lumpectomy rates since 2013 and an associated decline in mastectomies. The steady increase in CPM rates from 2005 to 2013 has since stabilized. The reasons for the recent reversal in trends are likely multifactorial. Further qualitative and quantitative research is required to understand the factors driving these recent practice changes and their associations with patient-reported outcomes.
Topics: Breast Neoplasms; Female; Humans; Mastectomy; Mastectomy, Segmental; Postoperative Complications; Prophylactic Mastectomy; SEER Program; United States
PubMed: 35675047
DOI: 10.1001/jamasurg.2022.2065 -
JAMA Surgery Mar 2024Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery...
IMPORTANCE
Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery.
OBJECTIVE
To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM).
DESIGN, SETTING, AND PARTICIPANTS
An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care.
INTERVENTION
Surgery using a single-port robot and the surgical technique of the authors.
MAIN OUTCOMES AND MEASURES
Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation.
RESULTS
Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%).
CONCLUSION AND RELEVANCE
In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT05245812.
Topics: Humans; Female; Mastectomy; Robotics; Robotic Surgical Procedures; Breast Neoplasms; Nipples; Feasibility Studies
PubMed: 38231502
DOI: 10.1001/jamasurg.2023.6999