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Aesthetic Surgery Journal. Open Forum 2024The latissimus dorsi (LD) flap is a commonly used method for breast reconstruction after mastectomy. In this study, we present a long-term follow-up and effects of...
BACKGROUND
The latissimus dorsi (LD) flap is a commonly used method for breast reconstruction after mastectomy. In this study, we present a long-term follow-up and effects of refining surgery on patient satisfaction and quality of life after breast reconstruction with the extended LD flap, using the BREAST-Q questionnaire.
OBJECTIVES
The aim of this study was to investigate the patient-reported long-term results after breast reconstruction with the extended LD myocutaneous flap.
METHODS
A retrospective cohort study of adult patients ( = 101) who were operated on using the extended LD flap for breast reconstruction at the Linköping University Hospital during 1997 to 2012 was made using data retrieved from medical records. The patients were asked to complete the BREAST-Q questionnaire at 2 different postoperative time points.
RESULTS
Eighty-three patients replied to the first questionnaire, and 56 patients also replied to the second. Mean follow-up was 11.7 years. Higher age and living together with someone correlated to higher BREAST-Q results, while postoperative infection, bilateral LD flaps, smoking, and prior breast surgery had a negative impact on the results. Overall BREAST-Q results increased over time. No independent effect of refining surgery could be shown.
CONCLUSIONS
Patient satisfaction after breast reconstruction with the LD flap as measured with the BREAST-Q questionnaire is high and in line with other studies. The overall satisfaction with the reconstruction method seems to increase with time, but no further increase in satisfaction after refining surgery could be established.
PubMed: 38887215
DOI: 10.1093/asjof/ojae002 -
Asia-Pacific Journal of Clinical... Jun 2024Papillary lesions in the breast pose diagnostic and therapeutic challenges. Encapsulated papillary carcinoma (EPC) is a rare breast cancer. However, evidence-based...
BACKGROUND
Papillary lesions in the breast pose diagnostic and therapeutic challenges. Encapsulated papillary carcinoma (EPC) is a rare breast cancer. However, evidence-based guidelines are limited. For this reason, there is no complete clarity in diagnosis and treatment management, and there are insufficient studies in the literature. This study aimed to examine the necessity of sentinel lymph node sampling in the management of EPC, in line with patients' clinicopathological data.
METHODS
We retrospectively screened patients with EPC in our clinic between January 2012 and March 2022. We recorded and statistically evaluated patients' demographic, clinical, radiological, pathological, and treatment management.
RESULTS
Sixty-four patients with EPCs were identified. The final pathologic evaluation revealed that 19 patients (18.7%) had pure EPC, 27 patients (43.7%) had EPC with associated ductal carcinoma in situ and 18 patients (37.5%) had EPC associated with invasion. The mean age was 61 years, and two patients were male. Breast-conserving surgery was performed in 62 patients, and simple mastectomy was performed in two patients. Sentinel lymph node biopsy (SLNB) was positive in only one patient. Sixty-three patients with EPC were hormone receptor-positive, and one patient was triple-negative and was associated with invasion. None of the patients died, one had a local recurrence, and a mastectomy was performed.
CONCLUSIONS
The overall prognosis and long-term survival of patients with EPC were excellent. Our study and the current literature indicate that routine SLNB is overtreatment because surgical excision with negative margins is sufficient in EPC cases and lymph node metastasis is rare, even with an invasive component.
PubMed: 38886990
DOI: 10.1111/ajco.14090 -
Plastic and Reconstructive Surgery Jun 2024The use of post-mastectomy radiation therapy (PMRT) in the setting of immediate two-stage breast reconstruction is becoming increasingly widespread. However, the...
BACKGROUND
The use of post-mastectomy radiation therapy (PMRT) in the setting of immediate two-stage breast reconstruction is becoming increasingly widespread. However, the timeframe of tissue expander exchange for permanent implant placement following PMRT is not well-defined, and it remains unclear what time interval optimizes surgical outcomes and patient satisfaction.
METHODS
A systematic review conducted in accordance with PRISMA 2020 was completed. PubMed, Embase, Scopus, and Cochrane databases were searched under keywords pertaining to concepts of tissue expander breast reconstruction and PMRT. Inclusion criteria encompassed primary articles on tissue expander breast reconstruction with adjuvant radiation therapy reporting timing of exchange to permanent implant following radiation and surgical outcomes.
RESULTS
Of the initial 1,259 publications, 15 studies met our inclusion criteria, and 11 studies had granular enough data to use for pooled analysis. Implant exchange less than 6 months after PMRT was found to be associated with increased incidence of wound dehiscence (17.12% vs 3.64%, p<0.001) and hematoma (25% vs 2.59%, p<0.001) compared to exchange after 6 months. There was no significant difference in incidence of SSI, seroma, capsular contracture, and reconstructive failure.
CONCLUSIONS
Expander to implant exchange at less than 6 months is associated with a higher incidence of wound dehiscence and hematoma formation but does not increase the risk of reconstruction failure. The limited research on ideal timing prompts further investigation to optimize surgical outcomes for the increasing patient population undergoing PMRT and immediate two-staged breast reconstruction.
PubMed: 38886886
DOI: 10.1097/PRS.0000000000011588 -
Annals of Surgical Oncology Jun 2024Quality of surgical care is understudied for lobular inflammatory breast cancer (IBC), which is less common, more chemotherapy-resistant, and more mammographically...
INTRODUCTION
Quality of surgical care is understudied for lobular inflammatory breast cancer (IBC), which is less common, more chemotherapy-resistant, and more mammographically occult than ductal IBC. We compared guideline-concordant surgery (modified radical mastectomy [MRM] without immediate reconstruction following chemotherapy) for lobular versus ductal IBC.
METHODS
Female individuals with cT4dM0 lobular and ductal IBC were identified in the National Cancer Database (NCDB) from 2010-2019. Modified radical mastectomy receipt was identified via codes for "modified radical mastectomy" or "mastectomy" and "≥10 lymph nodes removed" (proxy for axillary lymph node dissection). Descriptive statistics, chi-square tests, and t-tests were used.
RESULTS
A total of 1456 lobular and 10,445 ductal IBC patients were identified; 599 (41.1%) with lobular and 4859 (46.5%) with ductal IBC underwent MRMs (p = 0.001). Patients with lobular IBC included a higher proportion of individuals with cN0 disease (20.5% lobular vs. 13.7% ductal) and no lymph nodes examined at surgery (31.2% vs. 24.5%) but were less likely to be node-negative at surgery (12.7% vs. 17.1%, all p < 0.001). Among those who had lymph nodes removed at surgery, patients with lobular IBC also had fewer lymph nodes excised versus patients with ductal IBC (median [interquartile range], 7 (0-15) vs. 9 (0-17), p = 0.001).
CONCLUSIONS
Lobular IBC patients were more likely to present with node-negative disease and less likely to be node-negative at surgery, despite having fewer, and more frequently no, lymph nodes examined versus ductal IBC patients. Future studies should investigate whether these treatment disparities are because of surgical approach, pathologic assessment, and/or data quality as captured in the NCDB.
PubMed: 38886328
DOI: 10.1245/s10434-024-15540-1 -
Aesthetic Plastic Surgery Jun 2024To summarize the experiences on the mastoscopic subcutaneous mastectomy for gynecomastia by "nine-step method" based on the "5S" goal and standardize this operation.
BACKGROUND
To summarize the experiences on the mastoscopic subcutaneous mastectomy for gynecomastia by "nine-step method" based on the "5S" goal and standardize this operation.
PATIENTS AND METHODS
Between January 1, 2002, and October 31, 2021, a total of 2035 breasts of 1082 male patients with gynecomastia, of which 129 patients with one side, were underwent mastoscopic subcutaneous mastectomy. The follow-up endpoint was 3 months after surgery.
RESULTS
All patients were successfully completed the operation, and none of them was transferred to open operation. The operation time for unilateral breast was 12-28 min, and the average time was 17.7 ± 6.2 min. The amount of bleeding during unilateral operation was very small, about 5-10 ml. The total drainage volume was 5-50 ml after the operation, and the drainage tube was removed in 3-5 days. The epidermal necrosis occurred in 0.3% nipple. 0.2% chest wall had a little ecchymosis in the supero-medial region of the breast. All patients had the normal feeling of nipples and areola, the smoothing and symmetrical chest wall, and the natural contour. There was no recurrence during the follow-up period.
CONCLUSIONS
The mastoscopic subcutaneous mastectomy for gynecomastia by "nine-step method" based on the "5S" goal has a short operation time, few surgical complications and good esthetics. It achieves the "5S" goals on the complete removal of glandular tissue (sweeping), small and scar-hidden incision are small (scarless), good symmetry of bilateral chest wall (symmetry), normal chest shape (shape), and smoothing chest wall (smoothing).
LEVEL OF EVIDENCE III
The journal asks authors to assign a level of evidence to each article. For a complete description of Evidence-Based Medicine ratings, see the Table of Contents or the online Instructions for Authors at www.springer.com/00266 .
PubMed: 38886195
DOI: 10.1007/s00266-024-04111-0 -
European Journal of Surgical Oncology :... Jun 2024The American Society of Breast Surgeons (ASBrS) recently classified oncoplastic breast conserving surgery (OBCS) into two levels. The association of resection ratio...
INTRODUCTION
The American Society of Breast Surgeons (ASBrS) recently classified oncoplastic breast conserving surgery (OBCS) into two levels. The association of resection ratio during OBCS with patient-reported outcomes (PRO) is unclear.
MATERIALS AND METHODS
Patients with stage 0-III breast cancer undergoing OBCS between 01/2011-04/2023 at a Swiss university hospital, who completed at least one postoperative BREAST-Q PRO questionnaire were identified from a prospectively maintained institutional database. Outcomes included differences in PROs between patients after ASBrS level I (<20 % of breast tissue removed) versus level II surgery (20-50 %).
RESULTS
Of 202 eligible patients, 129 (63.9 %) underwent level I OBCS, and 73 (36.1 %) level II. Six patients (3.0 %) who underwent completion mastectomy were excluded. The median time to final PROs was 25.4 months. Patients undergoing ASBrS level II surgery were more frequently affected by delayed wound healing (p < 0.001). ASBrS level was not found to independently predict any BreastQ domain. However, delayed wound healing was shown to reduce short-term physical well-being (estimated difference -26.27, 95 % confidence interval [CI] -39.33 to -13.22, p < 0.001). Higher age was associated with improved PROs.
CONCLUSION
ASBrS level II surgery allows the removal of larger tumors without impairing PROs. Preventive measures for delayed wound healing and close postoperative follow-up to promptly treat wound healing disorders may avoid short-term reductions in physical well-being.
PubMed: 38885597
DOI: 10.1016/j.ejso.2024.108478 -
Annals of Plastic Surgery Jul 2024Little is known about practice patterns and payments for immediate lymphatic reconstruction (ILR). This study aims to evaluate trends in ILR delivery and billing...
BACKGROUND
Little is known about practice patterns and payments for immediate lymphatic reconstruction (ILR). This study aims to evaluate trends in ILR delivery and billing practices.
METHODS
We queried the Massachusetts All-Payer Claims Database between 2016 and 2020 for patients who underwent lumpectomy or mastectomy with axillary lymph node dissection for oncologic indications. We further identified patients who underwent lymphovenous bypass on the same date as tumor resection. We used ZIP code data to analyze the geographic distribution of ILR procedures and calculated physician payments for these procedures, adjusting for inflation. We used multivariable logistic regression to identify variables, which predicted receipt of ILR.
RESULTS
In total, 2862 patients underwent axillary lymph node dissection over the study period. Of these, 53 patients underwent ILR. Patients who underwent ILR were younger (55.1 vs 59.3 years, P = 0.023). There were no significant differences in obesity, diabetes, or smoking history between the two groups. A greater percentage of patients who underwent ILR had radiation (83% vs 67%, P = 0.027). In multivariable regression, patients residing in a county neighboring Boston had 3.32-fold higher odds of undergoing ILR (95% confidence interval: 1.76-6.25; P < 0.001), while obesity, radiation therapy, and taxane-based chemotherapy were not significant predictors. Payments for ILR varied widely.
CONCLUSIONS
In Massachusetts, patients were more likely to undergo ILR if they resided near Boston. Thus, many patients with the highest known risk for breast cancer-related lymphedema may face barriers accessing ILR. Greater awareness about referring high-risk patients to plastic surgeons is needed.
Topics: Humans; Middle Aged; Female; Massachusetts; Breast Neoplasms; Lymph Node Excision; Mastectomy; Retrospective Studies; Healthcare Disparities; Aged; Adult; Axilla; Mastectomy, Segmental; Practice Patterns, Physicians'
PubMed: 38885166
DOI: 10.1097/SAP.0000000000003920 -
Annals of Plastic Surgery Jul 2024Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential...
PURPOSE
Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential component of this is deciding whether patients need hospital admission following elective procedures. The aim of this study is to investigate operative factors and patient outcomes when mastectomies with or without reconstruction are performed as ambulatory procedures versus planned inpatient admissions.
METHODS
Patient charts for those undergoing mastectomy with or without reconstruction were retrospectively analyzed ranging from March 2019 until February 2021. Factors such as demographic information, operative type, operating room time, cancer stage, total stay time in the medical environment, and postoperative complications were assessed and compared between the 2 groups.
RESULTS
A total of 89 patient charts were reviewed, 46 from before the COVID-19 pandemic and 43 from after the start of the pandemic. No differences were observed in demographic factors between the 2 groups. After surgical cases resumed a significant proportion, 79%, of mastectomies with or without reconstruction were performed in the ambulatory center, versus just 2% pre-COVID-19. Similarly, of all of these cases performed, only 19% resulted in hospital admission versus the previous rate of 100% (P < 0.00001). Together, these changes resulted in a significant reduction in length of stay of 39.77 ± 19.2 hours pre-COVID-19 versus 14.81 ± 18.4 hours afterward (P < 0.00001). Unfortunately, a higher number of patients who received surgery after the start of the pandemic elected to forego immediate reconstruction 49% versus 72% (P = 0.032). Most importantly, there were no observable differences found in 7-day readmission, reoperation, or emergency department visit between groups. There was also no difference in 30-day complication rate between groups.
CONCLUSIONS
Mastectomy with or without reconstruction can be safely performed in the ambulatory setting without additional risk of complications or negative patient factors. This divergence from traditional the protocol of inpatient overnight admission may contribute positively toward patient comfort, minimize the use of healthcare costs and resources, and allow for increased scheduling flexibility for patient and provider alike.
Topics: Humans; COVID-19; Mastectomy; Female; Retrospective Studies; Mammaplasty; Middle Aged; Ambulatory Surgical Procedures; Breast Neoplasms; Length of Stay; Adult; Pandemics; Aged; Postoperative Complications
PubMed: 38885164
DOI: 10.1097/SAP.0000000000003922 -
Annals of Plastic Surgery Jul 2024Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in... (Comparative Study)
Comparative Study
BACKGROUND
Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in ADM derivatives, few studies directly compare their outcomes in the setting of iPBR. We sought to conduct a large head-to-head study comparing 3 ADMs used across our institution.
METHODS
A multicenter retrospective review of patients undergoing iPBR with SurgiMend PRS (fetal bovine-derived; Integra Lifesciences, Princeton, NJ), AlloDerm (human-derived; LifeCell Corp, Bridgewater, NJ), or DermACELL (human-derived; Stryker Corp, Kalamazoo, MI) between January 2014 to July 2022 was performed. Primary outcomes included rates of unplanned explantation and total reconstructive failure. Secondary outcomes included 90-day postoperative complications and long-term rates of capsular contracture development.
RESULTS
A total of 738 patients (1228 breasts) underwent iPBR during the study period; 405 patients received DermACELL (54.9%), 231 received AlloDerm (31.3%), and 102 received SurgiMend PRS (13.8%). Rates of short-term complications, total reconstruction failure, reoperation within 90 days, capsular contracture, and unplanned explantation were comparable. These findings remained true upon multivariate analysis accounting for baseline differences between cohorts, whereby ADM type was not an independent predictor of any outcome of interest. Conversely, factors such as body mass index, diabetes mellitus, smoking history, neoadjuvant and adjuvant chemotherapy, adjuvant radiation, skin-sparing mastectomy, Wise pattern and periareolar incisions, use of tissue expanders, and a subpectoral plane of insertion were significant predictors of postoperative complications.
CONCLUSION
Low rates of complications support the equivalency of fetal bovine and human-derived ADMs in iPBR. Patient characteristics and operative approach are likely more predictive of postoperative outcomes than ADM derivative alone.
Topics: Humans; Female; Retrospective Studies; Acellular Dermis; Middle Aged; Adult; Collagen; Breast Neoplasms; Postoperative Complications; Breast Implants; Breast Implantation; Mammaplasty; Mastectomy; Treatment Outcome
PubMed: 38885163
DOI: 10.1097/SAP.0000000000003990 -
Annals of Plastic Surgery Jul 2024This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction modality for patients with...
OBJECTIVE
This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction modality for patients with postmastectomy radiation therapy (PMRT).
METHODS
A retrospective review was conducted on breast cancer patients with stage II-III disease who performed implant-based breast reconstruction following with PMRT between September 2016 and April 2022. The patients were categorized into two matched groups: (1) patients receiving prepectoral breast reconstruction (PBR) or (2) subpectoral breast reconstruction (SBR) followed by PMRT. Following reconstruction, the patients were further compared for PMRT with the tissue expander (PMRT-TE) versus PMRT with permanent implant (PMRT-PI). PROs were measured with BREAST-Q questionnaire. Early and late complications were recorded and analyzed.
RESULTS
A total of 55 eligible patients were recruited. Patients who underwent PBR reported significantly higher satisfaction with breasts scores (P = 0.003) compared with the SBR group. The PMRT-TE group had higher satisfaction with breasts (P = 0.001) but lower physical well-being (P = 0.029) scores compared with PMRT-PI group. Moreover, patients in SBR cohort had a higher risk of capsular contracture (Baker grade III or IV) (20.5% vs 6.3%) and implant dislocation (48.7% vs 12.5%) than patients in PBR cohort. Patients in PMRT-PI group had a slightly higher rate of capsular contracture (Baker grade III or IV) than PMRT-TE group (20.8% vs 12.9%).
CONCLUSIONS
PBR was associated with lower rates of late complications, especially for implant dislocation, and higher satisfaction with breasts scores compared to SBR. In addition, compared to PMRT-TE with PMRT-PI, patients in PMRT-TE cohort reported superior PROs of satisfaction with breasts.
Topics: Humans; Female; Patient Reported Outcome Measures; Retrospective Studies; Middle Aged; Breast Neoplasms; Mastectomy; Breast Implantation; Postoperative Complications; Breast Implants; Adult; Radiotherapy, Adjuvant; Patient Satisfaction; Mammaplasty
PubMed: 38885161
DOI: 10.1097/SAP.0000000000003974