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Journal of Plastic, Reconstructive &... Dec 2023Among plastic surgeons, there are several conventional techniques for performing chest surgery. Research on surgical approaches has focused cis-gender patients with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Among plastic surgeons, there are several conventional techniques for performing chest surgery. Research on surgical approaches has focused cis-gender patients with medical conditions, such as breast cancer or gynecomastia, but has never studied transgender populations. The aim of this study is to perform the first systematic review of gender-affirming surgery (GAS) in transgender populations and determine postoperative outcomes differences in relation to surgical technique.
METHODS
Two reviewers independently searched Medline, Embase, CINAHL, Web of Science, and Cochrane databases for studies published prior to 2021. Studies selected for inclusion were retrospective or prospective studies of adult transgender men undergoing GAS that utilized appropriate operative techniques and reported complications and/or patient-reported outcomes.
RESULTS
A total of 26 randomized controlled trials, including 40 distinct populations and 3055 patients, were identified. Surgical techniques compared double incision free nipple graft (DIFNG) (2053 patients [67.20%]), pedicled nipple techniques (PNT) (297 [9.72%]), and periareolar techniques (PAT) (705 [23.08%]). Pairwise analysis found the lowest complication rates associated with procedures utilizing DIFNG, followed by PNT, then PAT. Patients with PAT had significantly higher satisfaction scores than DIFNG.
CONCLUSIONS
This is the first systematic review to evaluate outcomes of chest surgery techniques among the transgender population. Results indicate significantly more complications for PAT compared to DIFNG or PNT. Analysis of patient-reported outcomes was limited due to heterogeneity in reporting.
Topics: Male; Adult; Humans; Retrospective Studies; Prospective Studies; Transsexualism; Transgender Persons; Outcome Assessment, Health Care; Thoracic Wall
PubMed: 37837944
DOI: 10.1016/j.bjps.2023.09.002 -
Annals of Surgical Oncology Mar 2024Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND.
METHODS
A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method.
RESULTS
A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen.
CONCLUSIONS
To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.
Topics: Humans; Female; Seroma; Lymph Node Excision; Mastectomy, Segmental; Drainage; Disease Progression; Axilla; Surgeons; Breast Neoplasms
PubMed: 38038792
DOI: 10.1245/s10434-023-14631-9 -
Journal of Plastic, Reconstructive &... Nov 2023Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients.
METHODS
A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
RESULTS
Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting.
CONCLUSIONS
In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.
Topics: Humans; Female; Mastectomy; Quality of Life; Treatment Outcome; Mammaplasty; Adipose Tissue; Breast Neoplasms
PubMed: 37797375
DOI: 10.1016/j.bjps.2023.09.026 -
Plastic and Reconstructive Surgery.... May 2024Breast reconstruction is a standard procedure in postmastectomy plastic surgery. The necessity of routine histological examinations for mastectomy scars during delayed...
BACKGROUND
Breast reconstruction is a standard procedure in postmastectomy plastic surgery. The necessity of routine histological examinations for mastectomy scars during delayed reconstruction remains a topic of debate. We evaluated the need for histological examination of scars during delayed breast reconstruction.
METHODS
We conducted a systematic review using PubMed, TDnet, and Cochrane Central in August 2023. Inclusion criteria involved delayed breast reconstruction with histological scar analysis and malignancy reporting. Exclusion criteria encompassed noncancerous breast diseases, prophylactic mastectomies, articles lacking relevant information, case reports, technique descriptions, and reviews. We independently assessed articles. Differences in recurrence rates were determined using a Z-test for proportions. A linear regression model explored the relationship between reconstruction timing and pathological results. The number needed to treat was calculated based on the literature. The Wilcoxon test was used to compare mean reconstruction times and postreconstruction follow-up between groups.
RESULTS
Our analysis covered 11 retrospective observational studies published between 2003 and 2018, including 3754 mastectomy scars. The malignancy recurrence rate was 0.19%, consistent with previous reports, with a number needed to treat of 144.93-188.68 patients. The timing of breast reconstruction postmastectomy averaged 19.9 months, without statistically significant association between reconstruction timing and recurrence rates. Postreconstruction follow-up periods ranged from 60 to 87 months. The postreconstruction adverse outcomes ratio was 2.21%.
CONCLUSIONS
Assessing the necessity of histological examination in breast reconstruction is complex. Based on the literature and this study, we do not recommend routine histological examination of mastectomy scars during delayed reconstruction. A selective approach based on risk factors may be beneficial, warranting further research.
PubMed: 38798931
DOI: 10.1097/GOX.0000000000005847 -
Annals of Surgical Oncology Dec 2023Preserving the nipple-areolar complex (NAC) in breast cancer surgery improves patient satisfaction and quality of life. The oncologic safety of NSM in tumors < 2 cm...
BACKGROUND
Preserving the nipple-areolar complex (NAC) in breast cancer surgery improves patient satisfaction and quality of life. The oncologic safety of NSM in tumors < 2 cm from the nipple remains in question. We conducted a systematic review to determine whether TND < 2 cm was associated with increased risk of LRR in patients undergoing NSM.
METHODS
We included studies of invasive or in situ breast cancer < 2 cm from NAC undergoing NSM which reported LRR rates. LRR rates were stratified by TND and culminated across studies. Cohort study quality was assessed using Newcastle-Ottawa Criteria. Meta-analysis was not possible due to heterogeneity in reporting survival outcomes.
RESULTS
We identified seven retrospective cohort studies with 2295 patients and 18 case series with 3507 patients. Direct tumor involvement of NAC was considered an absolute contraindication to NSM in all studies. In cohort studies, median follow-up was 31-112 (range 14-204) months. Cohorts with TND < 2 cm did not have a significantly higher rate of LRR. Amongst case series, 275 patients had TND < 2 cm. Combined LRR in case series was 2.6%, with median follow-up 10.4-71 (range 0-158) months.
CONCLUSIONS
Our systematic review did not identify TND < 2 cm as a significant risk factor for LRR. NSM appears oncologically safe in select patients with TND < 2 cm. Given the improved quality of life associated with NSM compared to skin-sparing mastectomy, we suggest NSM as the procedure of choice in appropriately selected patients.
Topics: Humans; Female; Mastectomy; Nipples; Cohort Studies; Retrospective Studies; Quality of Life; Breast Neoplasms; Carcinoma, Ductal, Breast; Mammaplasty
PubMed: 37620525
DOI: 10.1245/s10434-023-14143-6 -
Aesthetic Surgery Journal Oct 2023Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity...
Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity preservation, the scientific literature still reports contradictory findings. This systematic review aimed to assess whether breast reduction mammaplasty is associated with measurable changes in breast sensation. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed (National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), and Web of Science (Clarivate, Philadelphia, PA) databases were searched for clinical studies investigating breast sensation after breast reduction mammaplasty. The initial search identified 1523 studies of which 22 articles met our specific inclusion criteria. Most of the included studies are consistent in describing only transient sensation decrease or even sensation improvement after surgery compared to the presurgery condition with any approach, except those investigating outcomes after superior or superolateral pedicle reduction mammaplasty. Nevertheless, the overall quality of evidence is low or very low due to the limited availability of randomized controlled trials or controlled studies and the high risk of bias.
Topics: Female; Humans; Breast; Mammaplasty; Mastectomy; Sensation; Netherlands
PubMed: 37462608
DOI: 10.1093/asj/sjad234 -
Journal of Plastic, Reconstructive &... Mar 2024Flap neurotisation is a promising solution to restore the diminished or complete loss of sensation following mastectomy. This systematic review compared sensory outcomes... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Flap neurotisation is a promising solution to restore the diminished or complete loss of sensation following mastectomy. This systematic review compared sensory outcomes in neurotised versus non-neurotised abdominal-based autologous breast reconstructions to establish its benefit in routine clinical practice.
METHODS
A literature search was performed according to the PRISMA guidelines. Medline, PubMed, EMBASE, and Cochrane databases were queried for relevant studies. Pressure sensitivity, measured using Semmes-Weinstein monofilaments (SWM) or the pressure-specified sensory device (PSSD), was the primary outcome measure.
RESULTS
A total of 12 studies comprising 367 neurotised and 295 non-neurotised flap reconstructions were included, with 8 studies included in the meta-analysis. Neurotised flaps demonstrated superior sensory outcomes over non-neurotised flaps, with significant differences in SWM scores (mean difference [MD], -1.552 95% CI, -2.351 to -0.7535; p = 0.0001) and PSSD (MD -13.36; 95% CI, -26.41 to -0.3117; p = 0.0448) at follow-up (range 8 to 77 months). The differences in total skin sensation (native and flap skin combined) were statistically significant in the SWM group (p = 0.0010) but not in the PSSD group (p = 0.0649). Investigation on the factors impacting sensation recovery in neurotised flaps yielded inconclusive outcomes.
CONCLUSIONS
Neurotised flaps consistently demonstrated superior sensation outcomes compared with non-neurotised flaps, irrespective of flap type or neurotisation technique. However, further research is essential to elucidate the factors that impact sensory recovery and standardise neurotisation practices for more optimal post-mastectomy reconstruction outcomes.
Topics: Humans; Female; Mastectomy; Breast Neoplasms; Mammaplasty; Sensation; Surgical Flaps
PubMed: 38401199
DOI: 10.1016/j.bjps.2024.01.045 -
Aesthetic Plastic Surgery May 2024It is still a controversial debate that which type of immediate breast reconstruction should be operated on breast cancer patients in the setting of postmastectomy... (Meta-Analysis)
Meta-Analysis Comparative Study Review
BACKGROUND
It is still a controversial debate that which type of immediate breast reconstruction should be operated on breast cancer patients in the setting of postmastectomy radiotherapy. This meta-analysis compared incidence of complications requiring reoperation (CRR), reconstruction failure (RF) and patient-reported outcome between immediate autologous breast reconstruction (ABR) and immediate implant-based breast reconstruction (IBBR), tissue expander/implant reconstruction mostly, in the setting of postmastectomy radiotherapy.
METHODS
Systematic and thorough research was conducted to search for studies published before August 1, 2022, by using three online databases. Studies that covered complications or reconstruction failure between two cohorts were included. To evaluate the possible bias in the included studies, the Newcastle-Ottawa Scale was applied.
RESULTS
Eight studies presenting 1261 patients were enrolled. The relative risk associated with reconstructive failure favored IBBR (RR = 8.61; 95% CI, 2.84-26.08; P = 0.0001). While the risk for complications requiring reoperation was not significantly different between two groups, either include reconstruction failure (RR = 1.45 95% CI, 0.82-2.55; P = 0.20) or not (RR = 0.63 95% CI, 0.28-1.43; P = 0.27). However, because statistical definitions and methodologies vary, the synthesized result should be taken critically.
CONCLUSION
Patients with IBBR have more possibility experiencing RF compared that with ABR, while the chance for CRR is not that different between two groups. For the purpose of clinical practice refinement, more high-quality studies are needed.
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: Humans; Female; Breast Neoplasms; Breast Implantation; Mammaplasty; Mastectomy; Reoperation; Breast Implants; Postoperative Complications; Radiotherapy, Adjuvant; Transplantation, Autologous; Patient Reported Outcome Measures; Time Factors
PubMed: 37380747
DOI: 10.1007/s00266-023-03430-y -
Free Tissue Transfer for Reconstruction After Bilateral Skin Sparing Mastectomy-A Systematic Review.Annals of Plastic Surgery Apr 2024Breast cancer is the most commonly diagnosed malignant neoplasia in females worldwide. Overall survival and patients' choice for bilateral mastectomy have increased. It...
BACKGROUND
Breast cancer is the most commonly diagnosed malignant neoplasia in females worldwide. Overall survival and patients' choice for bilateral mastectomy have increased. It is therefore important to offer breast reconstructive procedures to improve patient quality of life and self-esteem. The aim of this systematic literature review is to quantify the outcome and sustainability of bilateral breast reconstruction using autologous, vascularized free tissue transfer.
METHODS
A systematic literature review of PubMed, Cochrane, and the Web of Science databases was performed. A total of 5879 citations were identified, and 12 studies met the inclusion criteria.
RESULTS
A total of 1316 patients were included, with a mean age of 47.2 years. Overall, 32.5% of patients experienced a complication after breast reconstruction. If reported, 7.45% of patients experienced major complications, while 20.7% had minor complications.The following flaps were used for breast reconstruction, in order of reducing frequency: DIEP (45.45%), TRAM (22.73%), SIEA (9.09%), SGAP (9.09%), TUG (4.55%), TMG (4.55%), and LD/MLD (4.55%).
CONCLUSIONS
Current studies indicate that bilateral breast reconstruction using autologous, vascularized free tissue transfer is a safe procedure for postmastectomy reconstruction and offers stable long-term results. This is particularly in comparison to implant-based breast reconstruction.
Topics: Female; Humans; Middle Aged; Mastectomy; Breast Neoplasms; Quality of Life; Mammaplasty; Surgical Flaps; Retrospective Studies
PubMed: 38470816
DOI: 10.1097/SAP.0000000000003828 -
Oncological safety of nipple-sparing mastectomy after neoadjuvant chemotherapy: a systematic review.Revista Do Colegio Brasileiro de... 2023the use of nipple-sparing mastectomy (NSM) in local advanced breast cancer after neoadjuvant chemotherapy (NQT) is increasing, despite few studies on the subject. The...
BACKGROUND
the use of nipple-sparing mastectomy (NSM) in local advanced breast cancer after neoadjuvant chemotherapy (NQT) is increasing, despite few studies on the subject. The aim of this systematic review was to determine the safety of NSM after neoadjuvant chemotherapy.
METHODS
for this systematic review we searched MEDLINE; Cochrane; Scientific Electronic Library Online (SciELO); Embase and Scopus. A literature search of all original studies including randomized controlled trials, cohort studies and case-control studies comparing women undergoing NSM after neoadjuvant chemotherapy for breast cancer was undertaken. Outcomes were locoregional recurrence (LRR), nipple recurrence and distant recurrence (DR). Data analysis was undertaken to explore the safety of NSM after NQT. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021276778.
FINDINGS
a total of 437 articles were identified. Four articles were included with 1466 patients all of which had a high to serious risk of overall bias. Local recurrence in the NSM after the NQT group ranged from zero to 9.8%. Nippleareolar complex (NAC) recurrence ranged from zero to 2.1%. The distant recurrence rate ranged from 6.5% to 16%. Due to the lack of pattern among the control groups, it was not possible to perform a meta-analysis.
INTERPRETATION
this review provides information for decision making in performing NSM after NQT. Despite the low rates of local recurrence and patients should be counseled about limited oncological information.
Topics: Humans; Female; Breast Neoplasms; Mastectomy; Neoadjuvant Therapy; Nipples; Organ Sparing Treatments; Retrospective Studies; Neoplasm Recurrence, Local
PubMed: 37556611
DOI: 10.1590/0100-6991e-20233515-en