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Updates in Surgery Jun 2024There is limited evidence on the ideal retention thickness of skin flap in mastectomy. Residual breast tissue (RBT) after mastectomy still represents an unknown risk for... (Review)
Review
BACKGROUND
There is limited evidence on the ideal retention thickness of skin flap in mastectomy. Residual breast tissue (RBT) after mastectomy still represents an unknown risk for local recurrence or new breast cancer lesions. We made this systematic review to identify the optimal flap after mastectomy with minimal complications and better oncological safety.
METHODS
A systematic review was performed using MEDLINE search in PubMed, Embase, and Cochrane Library with the search terms relevant to skin flap thickness and residual breast tissue in breast cancer patients undergoing mastectomy.
RESULTS
Twenty-one studies were included of which fifteen studies enrolled 3814 patients who received mastectomy, and additional six studies were based on cadavers or breast specimens. Four studies confirmed the presence of the superficial fascial layer (Camper's fascia) which can theoretically be used as an anatomical marker for flap retention during mastectomy. Two other studies confirmed Camper's fascia deficiency to a greater or lesser extent. The flap thickness ranged from 3.8 mm to 23 mm in 2692 patients of 7 studies, which was related to BMI, breast size, and examination modalities. Two retrospective and one prospective studies confirmed flaps exceeding 5 mm could significantly increase postoperative complications. Nine studies including 1122 patients explored the association among flap thickness, RBT, and complications, 3 studies of which confirmed excessive flap thickness could cause a significant increase in RBT, which proved to be a potential risk factor for local recurrence in 3 studies. Flaps beyond 5 mm were also found to significantly increase the chance of local recurrence in 4 studies.
CONCLUSION
Camper's fascia can serve as an ideal demarcation between fat and breast tissue based on most current studies. 5 mm thickness of the flap retention in mastectomy is recommended if Camper's fascia is absent or obscure, through which better cosmetic outcomes and less RBT can be achieved.
Topics: Humans; Breast Neoplasms; Surgical Flaps; Mastectomy; Female; Breast; Postoperative Complications; Mammaplasty; Neoplasm Recurrence, Local
PubMed: 37864625
DOI: 10.1007/s13304-023-01675-5 -
Plastic and Reconstructive Surgery.... Oct 2023Breast-conserving therapy with oncoplastic reduction is a useful strategy for partial mastectomy defect reconstruction. The most recently published systematic review of...
BACKGROUND
Breast-conserving therapy with oncoplastic reduction is a useful strategy for partial mastectomy defect reconstruction. The most recently published systematic review of oncoplastic breast reduction outcomes from 2015 showed wound dehiscence in 4.3%, hematoma in 0.9%, infection in 2.8%, and nipple necrosis in 0.9% of patients. We performed a systematic review of oncoplastic breast reduction literature, comparing outcomes and complication rates reported over the past 8 years.
METHODS
Studies describing the use of oncoplastic breast reduction and discussion of postoperative complications were included. The primary outcome assessed was the postoperative complication rate; secondary outcomes analyzed were rates of margin expansion, completion mastectomy, and delays in adjuvant therapy due to complications.
RESULTS
Nine articles met inclusion criteria, resulting in 1715 oncoplastic breast reduction patients. The mean rate of hematoma was 3%, nipple necrosis was 2%, dehiscence was 4%, infection was 3%, and seroma was 2%. The need for re-excision of margins occurred in 8% of patients, and completion mastectomy in 2%. Finally, delay in adjuvant treatment due to a postoperative complication occurred in 4% of patients.
CONCLUSIONS
Oncoplastic breast reduction is an excellent option for many patients undergoing breast-conserving therapy; however, postoperative complications can delay adjuvant radiation therapy. Results of this systematic literature review over the past 8 years showed a slight increase in complication rate compared to the most recent systematic review from 2015. With increased popularity and surgeon familiarity, oncoplastic breast reduction remains a viable option for reconstruction of partial mastectomy defects despite a slight increase in complication rate.
PubMed: 37850204
DOI: 10.1097/GOX.0000000000005355 -
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 -
Journal of Clinical Medicine Sep 2023Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural,... (Review)
Review
Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.
PubMed: 37834779
DOI: 10.3390/jcm12196135 -
Journal of Plastic, Reconstructive &... Dec 2023The impact of neoadjuvant chemotherapy (NACT) on the complication rate after implant-based and autologous breast reconstruction remains unclear. The aim of this study... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The impact of neoadjuvant chemotherapy (NACT) on the complication rate after implant-based and autologous breast reconstruction remains unclear. The aim of this study was to systematically review and perform a meta-analysis of previously published studies on immediate breast reconstruction (IBR) in breast cancer patients treated with NACT compared with controls.
METHODS
PubMed and EMBASE were searched to identify studies assessing the impact of NACT on major and minor complications after IBR. The primary effect measures were relative risk (RR), 95% confidence interval (95% CI), and p-value.
RESULTS
Eight studies comprising 51,731 patients were included in the meta-analysis. Of these, 5161 patients received NACT and 46,570 patients did not receive NACT. In regard to major complications, NACT did not statistically significant increase the rate of reconstructive failure (RR = 1.35, 95% CI = 0.96-1.91, p = 0.09), the rate of mastectomy skin-flap necrosis (RR = 1.39, 95% CI = 0.61-3.17, p = 0.44), or the rate of reoperation (RR = 1.09, 95% CI = 0.87-1.37, p = 0.45). Regarding minor complications, NACT did not significantly increase the rate of wound complications (RR = 1.05, 95% CI = 0.87-1.28, p = 0.62). In a subgroup analysis of implant-based breast reconstruction following NACT, single-stage direct-to-implant (DTI) had a significantly lower implant failure rate compared with two-staged tissue expander/implant (TE/I) (RR = 0.43, 95% CI = 0.26-0.71, p = 0.0011).
CONCLUSION
NACT did not increase the major or minor complication rate after IBR with either autologous tissue or implants. Thus, NACT and IBR should be considered safe procedures. The review of studies describing patients undergoing implant-based breast reconstruction following NACT could indicate that single-stage DTI was a safer procedure than two-staged TE/I. However, the association requires further evaluation.
Topics: Humans; Female; Mastectomy; Neoadjuvant Therapy; Breast Neoplasms; Mammaplasty; Postoperative Complications; Treatment Outcome; Breast Implants; Retrospective Studies
PubMed: 37804643
DOI: 10.1016/j.bjps.2023.09.048 -
Aesthetic Plastic Surgery Oct 2023Breast implant capsule-associated squamous cell carcinoma is exceedingly rare, with only eleven previously published cases. The present study systematically reviews the... (Review)
Review
Breast implant capsule-associated squamous cell carcinoma is exceedingly rare, with only eleven previously published cases. The present study systematically reviews the current literature and describes an additional case in a 56-year-old patient who had undergone previous breast implant augmentation with textured silicone implants 22 years prior. Systematic review of the literature demonstrated a scarcity of reported cases, yielding only eleven other incidences. Symptomatology for this patient involved pain, swelling, and erythema of the right breast prior to eventual surgery. Magnetic resonance imaging reporting extensive oedema and a large periprosthetic effusion with lobulated changes. The patient proceeded with bilateral capsulectomies and histology demonstrated moderately differentiated squamous cell carcinoma, areas of squamous metaplasia, and a chronic inflammatory cell infiltrate. Postoperatively, a positron-emission tomography scan showed no concerning uptake of fluorodeoxyglucose and no evidence of metastatic disease. The patient proceeded to a right-sided total mastectomy and axillary lymph node biopsy. Final histology demonstrated remnant well-differentiated squamous cell carcinoma, whilst five lymph nodes were negative of disease. The patient received postoperative radiation therapy. A clinical history of swelling and pain appears to be a common presentation for this condition. Aspirations of periprosthetic collections containing squamous cells should be considered concerning for neoplasm. The presence of squamous metaplasia within the specimen provides some credence for transformation to invasive carcinoma mediated through chronic inflammation. The presence of perineural invasion would be worth reporting in future cases as it may confer similar risk characteristics as in cutaneous squamous cell carcinoma. A finding of remnant carcinoma during completion mastectomy provides support for an aggressive approach to surgical resection. LEVEL OF EVIDENCE V: 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 .
PubMed: 37798500
DOI: 10.1007/s00266-023-03693-5 -
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 -
Journal of Plastic, Reconstructive &... Nov 2023Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma.... (Meta-Analysis)
Meta-Analysis Review
Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM. A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. Pooled rates of patient demographics and outcomes were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complications in studies comparing reconstruction with and without ADM. In total, 515 reconstructions from four studies were included. Most cases were nipple-sparing mastectomies and utilized tissue-expander reconstructions. Meta-analysis demonstrated no significant difference in the rate of complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and 2.8% in no-ADM), seroma (1.2% and 8.3%, respectively), hematoma (1.2% and 2.1%), infection (4.7% and 4.2%), and mastectomy flap ischemia and/or necrosis (2.4% and 5.2%). Long-term complications included rippling (3.3% in ADM and 5.1% in no-ADM cohorts) and capsular contracture (6.8% and 3.4%, respectively). This meta-analysis demonstrated no difference in the rate of complications between cases with and without ADM. However, the outcomes data from no-ADM reconstruction mostly reflect robust mastectomy flaps. Surgeon discretion as informed by specific clinical scenarios should guide decisions regarding the use of ADM in prepectoral breast reconstruction.
Topics: Humans; Female; Mastectomy; Acellular Dermis; Breast Implantation; Seroma; Breast Neoplasms; Mammaplasty; Breast Implants; Retrospective Studies
PubMed: 37793198
DOI: 10.1016/j.bjps.2023.09.042 -
European Journal of Surgical Oncology :... Nov 2023This systematic review and meta-analysis aimed to synthesize the evidence on the preoperative characteristics, operative outcomes, and postoperative complications of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This systematic review and meta-analysis aimed to synthesize the evidence on the preoperative characteristics, operative outcomes, and postoperative complications of simple and complex segmentectomy for lung cancer.
METHODS
A systematic review of EMBASE (through Ovid), MEDLINE (via PubMed), and Cochrane CENTRAL (January 1990 - January 2023) was done. We included studies to compare simple versus complex segmentectomies for lung cancer in terms of characteristics and operative and postoperative outcomes.
RESULTS
There was a statistically significant difference regarding higher operative time in favor of simple segmentectomies (Mean Difference, MD = 15.76, 95% Confidence Interval, CI: 2.46 - 29.07, p = 0.02). The incidence of postoperative complications did not change between the two groups (Risk Ratio, RR = 0.86, 95% CI: 0.66 - 1.13, p = 0.27). There were no significant differences regarding postoperative length of hospital stay between simple or complex segmentectomies (MD = -0.02, 95% CI: 0.56 - 0.51, p = 0.93).
CONCLUSIONS
Simple and complex segmentectomies have comparable postoperative outcomes; in particular, postoperative complication rates and length of hospital stay were similar. Complex segmentectomies were associated with a longer operative time.
Topics: Humans; Lung Neoplasms; Mastectomy, Segmental; Postoperative Complications; Length of Stay
PubMed: 37778194
DOI: 10.1016/j.ejso.2023.107101 -
Cancers Sep 2023Breast augmentation is considered safe, but rare cases of breast implant-associated squamous cell carcinoma (BIA-SCC) have been reported. This study aimed to... (Review)
Review
Breast augmentation is considered safe, but rare cases of breast implant-associated squamous cell carcinoma (BIA-SCC) have been reported. This study aimed to systematically review published cases of BIA-SCC, providing valuable clinical data. The review included 14 articles and 18 cases of BIA-SCC. An increasing trend in reported BIA-SCC cases was observed, with four cases in the 1990s and 14 cases since 2010. The mean age of affected patients was 56 years, and symptoms typically appeared around 21 years after breast augmentation. Silicone implants used in cosmetic procedures were most commonly associated with BIA-SCC. Implant removal was necessary in all cases, and some patients required a mastectomy. Treatment approaches varied, with the selective use of chemotherapy and/or radiotherapy. The estimated 6-month mortality rate was 11.1%, while the 12-month mortality rate was 23.8%. The estimated 6-month mortality rate should be cautiously interpreted due to the limited sample size. It appears lower than the rate reported by the American Society of Plastic Surgeons, without clear reasons for this discrepancy. This study highlights the importance of enhanced monitoring and information sharing to improve detection and management of BIA-SCC. Healthcare providers should maintain vigilance during the long-term follow-up of breast augmentation patients.
PubMed: 37760485
DOI: 10.3390/cancers15184516