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Plastic and Reconstructive Surgery.... Jun 2024The study investigated the expectations of patients undergoing immediate breast reconstruction after mastectomy, considering factors such as the cause for mastectomy...
BACKGROUND
The study investigated the expectations of patients undergoing immediate breast reconstruction after mastectomy, considering factors such as the cause for mastectomy (cancer versus prophylactic due or gene mutations), age, marital status, and education.
METHODS
The study had a cross-sectional design. Eligible patients at Oslo University Hospital received a link to the BREAST-Q Expectations questionnaire, which they filled out before surgery from 2019 to 2022.
RESULTS
One hundred forty-six patients completed the questionnaire (79.8% response rate). The mean age was 46.6 years, and the majority (95.1%) were undergoing reconstruction with implants. Most patients (86.9%) wanted to be involved in the decision-making. The highest expectation was for breast appearance and the lowest for sensation after surgery. Patients not diagnosed with cancer (n = 27) before surgery expected significantly more pain after surgery compared with patients diagnosed with cancer ( = 0.016). Patients 40 years or younger had higher expectation of pain after surgery than patients 41 years or older, 73.2 versus 54.2, < 0.001, respectively. After 10 years, 26.7% of the patients expected that further reconstruction procedures might be necessary.
CONCLUSIONS
Our study's results regarding patient's expectations with breast reconstruction, as assessed using the BREAST-Q Expectations module, align with previous research in terms of overall trends. However, our study provides a more nuanced understanding by exploring variations within different patient subgroups. These differences emphasize the need for personalized preoperative counseling and support to align patient's expectations with realistic outcomes.
PubMed: 38903141
DOI: 10.1097/GOX.0000000000005928 -
Annals of Surgery Open : Perspectives... Mar 2024To investigate the possible association between breast implant illness (BII) and mast cell activation syndrome (MCAS), which often manifests increased mast cells (MCs)...
OBJECTIVE
To investigate the possible association between breast implant illness (BII) and mast cell activation syndrome (MCAS), which often manifests increased mast cells (MCs) in assorted tissues and may explain BII symptoms.
BACKGROUND
Mechanisms by which implants cause BII symptoms remain unclear, but BII and MCAS symptom profiles heavily overlap, warranting investigation of potential linkage.
METHODS
We retrospectively analyzed 20 implant patients who underwent explantation and total capsulectomy; 15 self-reported preoperatively they had BII (subject group); 5 felt they did not [control group 1 (CG1)]. Five prophylactic mastectomy patients constituted control group 2 (CG2). Subjects and CG1 patients completed BII symptom questionnaires preoperatively and multiple points postoperatively. With CD117 staining, average and maximum mast cell counts (MCCs) in resected tissues were determined.
RESULTS
Mean BII symptom score 2 weeks postexplantation was reduced by 77% ( < 0.0001), and 85% by 9 months. Analysis suggested BII in CG1 patients, too, who improved similarly. Among CG2 patients, healthy breast tissue showed mean and maximum MCCs of 5.0/hpf and 6.9/hpf. Mean and maximum MCCs in capsules in BII patients were 11.7/hpf and 16.3/hpf, and 7.6/hpf and 13.3/hpf in CG1 patients. All intergroup comparisons were significantly different ( < 0.0001).
CONCLUSIONS
MCCs in peri-implant capsules in BII patients are increased; some implanted patients appear to have unrecognized BII. Given that neoantigenic/xenobiotic exposures commonly trigger dysfunctional MCs in MCAS to heighten aberrant mediator expression driving inflammatory and other issues, further investigation of whether BII represents an implant-driven escalation of preexisting MCAS and whether an MCAS diagnosis flags risk for BII seems warranted.
PubMed: 38883946
DOI: 10.1097/AS9.0000000000000398 -
Annals of Plastic Surgery Jun 2024Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation...
BACKGROUND
Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps.
METHODS
For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis.
RESULTS
Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood.
CONCLUSION
Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.
Topics: Humans; Female; Mammaplasty; Middle Aged; Perforator Flap; Adult; Retrospective Studies; Breast Neoplasms; Epigastric Arteries; Microsurgery; Treatment Outcome; Postoperative Complications; Mastectomy; Length of Stay
PubMed: 38857013
DOI: 10.1097/SAP.0000000000003950 -
Annals of Plastic Surgery Jun 2024Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the...
INTRODUCTION
Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the nipple-areolar complex (NAC) and an X-shaped purse string closure after implant-based reconstruction.
METHODS
A retrospective review was performed on patients undergoing periareolar SSM and immediate implant-based reconstruction from January 2015 through December 2022, specifically identifying those patients who had square NAC excision and skin closure.
RESULTS
Twenty-nine patients met the inclusion criteria. They underwent 54 periareolar SSM and immediate implant-based reconstruction (bilateral 25, unilateral 4). Indications for surgery were cancer (30) and prophylactic (24; 2 patients had bilateral cancer). Reconstructive methods included tissue expander (TE) (36 [66.7%]) and direct-to-implant (DTI) (18 [33.3%]). The mean mastectomy weights and final implant sizes were similar between the 2 groups. Overall wound complications occurred in 13 (24.1%) of the breasts: mastectomy skin flap necrosis (MSFN; 10 [18.5%]) and infection (3 [5.6%]). Reconstructive failure occurred in 3 cases: TE, 1 (infection); DTI, 2 (MSFN/exposure). MSFN by reconstructive method: TE, 4 (11.1%); DTI, 6 (33.3%) (P = 0.05, comparing MSFN rates between TE and DTI methods). The mean initial TE fill volume was 247.1 cc; mean implant size in the DTI group was 417.8 cc (P < 0.0001).
CONCLUSIONS
The square NAC excision and closure can minimize the surgical incision in implant reconstruction. Two-stage TE reconstruction permits lower initial fill volumes, which reduces the risk of MSFN after box to X closure of SSM and implant-based reconstruction. It is useful in small- to moderate-sized breasts with mild ptosis in patients who are not candidates for NSM.
Topics: Humans; Female; Retrospective Studies; Middle Aged; Breast Neoplasms; Adult; Mastectomy, Subcutaneous; Mammaplasty; Breast Implants; Breast Implantation; Nipples; Organ Sparing Treatments; Aged; Mastectomy; Treatment Outcome
PubMed: 38857011
DOI: 10.1097/SAP.0000000000003946 -
Breast Cancer Research and Treatment Jun 2024The NCCN guidelines recommend genetic testing in those patients at increased risk of breast cancer in order to identify candidates for increased frequency of screening...
PURPOSE
The NCCN guidelines recommend genetic testing in those patients at increased risk of breast cancer in order to identify candidates for increased frequency of screening or prophylactic mastectomy. However, genetic testing may now identify patients who may benefit from recently developed targeted breast cancer therapy. In order to more widely identify these patients, we implemented genetic counseling for all patients diagnosed with breast cancer.
METHODS
In 2021, all patients evaluated within a Midwestern community hospital system diagnosed with breast cancer were offered genetic counseling. This group of patients was compared to a cohort of patients in 2021 who were offered genetic counseling based on NCCN guidelines. With Pearson's chi square, Fisher's Exact test, Mann-Whitney U, and multivariate regression as appropriate, individual demographic data and genetic testing completion between 2019 and 2021 were evaluated.
RESULTS
A total of 973 patients were reviewed. 439 were diagnosed with breast cancer in 2019 and 534 in 2021. Demographics and stage at diagnosis (p = 0.194) were similar between years. Completion of genetic testing increased from 204 (46.5%) in 2019 to 338 (63.3%) in 2021 (p < 0.01) with the universal counseling protocol. Specifically, genetic testing completion increased significantly in older patients (p = 0.041) and patients receiving Medicare benefits (p = 0.005). The overall pathogenic variants found increased from 32 to 39 with the most common including BRCA2 (n = 11), CFTR (n = 9), CHEK2 (n = 8), BRCA1 (n = 6).
CONCLUSION
Universal genetic counseling was related to a significant increase in genetic testing completion and an increase in pathogenic variants found among breast cancer patients, specifically in subpopulations which may have been previously excluded by traditional NCCN genetic testing screening guidelines.
PubMed: 38822953
DOI: 10.1007/s10549-024-07329-3 -
Gynecologie, Obstetrique, Fertilite &... May 2024
PubMed: 38821450
DOI: 10.1016/j.gofs.2024.05.004 -
Plastic and Reconstructive Surgery.... May 2024Few series report on using fat grafting as the primary form of breast reconstruction. A 9-year experience with absorbable biosynthetic scaffolds, used in place of...
BACKGROUND
Few series report on using fat grafting as the primary form of breast reconstruction. A 9-year experience with absorbable biosynthetic scaffolds, used in place of silicone implants, for breast reconstruction is reviewed.
METHODS
A clinical quality improvement approach was used to evaluate real-world data on a single plastic surgeon's experience treating breast reconstruction patients over a 7-year period.
RESULTS
Fifty-three patients had 74 breasts reconstructed, (following 51 therapeutic mastectomies and 23 prophylactic). Five of the 51 breasts (9.80 %) developed a local recurrence (mean follow-up of 4.5-5.5 years). This compared favorably with the practice's previous 6 years of silicone reconstructions. The most common complications were benign fat necrosis and oil cysts. More than 100 radiologic examinations were performed without interference by the absorbable implants. By 12-18 months post implantation, very little immune response was seen on histologic examinations of the biosynthetic scaffold constructs. Mature collagen and robust vascularity characterized the "mesh zone," whereas regenerated adipose tissue was seen in between and on top of the folded sheets of the implants. The average number of fat graft sessions in immediate reconstructions was 2.3, with a mean total fat graft volume of 551 mL, to restore an average mastectomy defect volume of 307 mL. Aesthetic outcomes were much better in the immediate reconstruction of nipple-sparing mastectomy group, which saw 68% achieve an A/B grade; 19%, C grade; and 13%, D/F on subjective grading.
CONCLUSION
This composite strategy, using biosynthetic scaffold and autologous fat grafting, yielded outcomes equivalent to flap reconstructions with the ease of implants.
PubMed: 38798934
DOI: 10.1097/GOX.0000000000005821 -
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 May 2024Many women eligible for breast conservation therapy (BCT) elect unilateral mastectomy (UM) with or without contralateral prophylactic mastectomy (CPM) and cite a desire...
BACKGROUND
Many women eligible for breast conservation therapy (BCT) elect unilateral mastectomy (UM) with or without contralateral prophylactic mastectomy (CPM) and cite a desire for "peace of mind." This study aimed to characterize how peace of mind is defined and measured and how it relates to surgical choice.
METHODS
Nine databases were searched for relevant articles through 8 October 2023, and data were extracted from articles meeting the inclusion criteria.
RESULTS
The inclusion criteria were met by 20 studies. Most were prospective cohort studies (65%, 13/20). In the majority of the studies (72%, 13/18), Non-Hispanic white/Caucasian women comprised 80 % or more of the study's sample. Almost half of the studies used the phrase "peace of mind" in their publication (45%, 9/20), and few directly defined the construct (15%, 3/20). Instead, words representing an absence of peace of mind were common, specifically, "anxiety" (85%, 17/20), "fear" (75%, 15/20), and "concern" (75%, 15/20). Most of the studies (90%, 18/20) measured peace of mind indirectly using questionnaires validated for anxiety, fear, worry, distress, or concern, which were administered at multiple postoperative time points (55%, 11/20). Most of the studies (95%, 18/19) reported at least one statistically significant result showing no difference in peace of mind between BCT, UM, and/or CPM at their latest time of assessment.
CONCLUSION
Peace of mind is largely framed around concepts that suggest its absence, namely, anxiety, fear, and concern. Existing literature suggests that peace of mind does not differ among average-risk women undergoing BCT, UM, or CPM. Shared surgical decisions should emphasize at least comparable emotional and/or psychosocial well-being between CPM and breast conservation.
PubMed: 38717543
DOI: 10.1245/s10434-024-15360-3 -
Annals of Plastic Surgery Jun 2024This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast...
This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction.
Topics: Humans; Mammaplasty; Free Tissue Flaps; Female; Middle Aged; Mastectomy; Retrospective Studies; Breast Neoplasms; Transplantation, Autologous; Adult; Time Factors; Postoperative Complications
PubMed: 38717156
DOI: 10.1097/SAP.0000000000003900