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Aesthetic Plastic Surgery Feb 2023Breast reconstruction is the mainstay treatment choice for patients subjected to a mastectomy. Prepectoral implant-based breast reconstruction (IBBR) is deemed to be a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Breast reconstruction is the mainstay treatment choice for patients subjected to a mastectomy. Prepectoral implant-based breast reconstruction (IBBR) is deemed to be a promising alternative to subpectoral reconstruction. Postmastectomy radiation therapy (PMRT) is necessary for locoregional recurrence control and to improve the disease-free survival rate in locally advanced breast cancer. This systematic review and meta-analysis study was designed to reveal the surgical, aesthetic, and oncological outcomes of prepectoral IBBR after PMRT.
METHODS
An extensive literature search was performed from inception to March 28, 2022. All clinical studies that included patients who were subjected to prepectoral IBBR and PMRT were included. Studies that included patients who received radiation therapy before prepectoral IBBR were excluded.
RESULTS
This systematic review included six articles encompassing 1234 reconstructed breasts. Of them, 391 breasts were subjected to PMRT, while 843 breasts were not subjected. Irradiated breasts were more susceptible to develop wound infection (RR 2.49; 95% 1.43, 4.35; P = 0.001) and capsular contracture (RR 5.17; 95% 1.93, 13.80; P = 0.001) than the non-irradiated breasts. Furthermore, irradiated breasts were more vulnerable to losing implants (RR 2.89; 95% 1.30, 6.39; P = 0.009) than the non-irradiated breast. There was no significant difference between both groups regarding the risk of implant extrusion (RR 1.88; 95% 0.20, 17.63; P = 0.58).
CONCLUSIONS
Patients with prepectorally IBBR and PMRT were more vulnerable to developing poor outcomes. This included a higher risk of breast-related and implant-related adverse events.
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; Mastectomy; Breast Implantation; Breast Implants; Treatment Outcome; Postoperative Complications; Neoplasm Recurrence, Local; Mammaplasty; Retrospective Studies
PubMed: 35879475
DOI: 10.1007/s00266-022-03026-y -
Plastic and Reconstructive Surgery May 2017Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for... (Review)
Review
BACKGROUND
Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.
METHODS
A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.
RESULTS
High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.
CONCLUSION
Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, V.
Topics: Female; Humans; Mammaplasty; Meta-Analysis as Topic; Perioperative Care; Prospective Studies; Randomized Controlled Trials as Topic
PubMed: 28445352
DOI: 10.1097/PRS.0000000000003242 -
Aesthetic Plastic Surgery Feb 2023Breast reconstruction can improve the quality of patients' lives by restoring the breasts' natural appearance. Saline-based tissue expanders are associated with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Breast reconstruction can improve the quality of patients' lives by restoring the breasts' natural appearance. Saline-based tissue expanders are associated with significant drawbacks. The current systematic review and meta-analysis aimed to reveal the usability, safety, and economic burden of AeroForm-based tissue expanders for breast reconstruction.
METHODS
An extensive systematic literature review was implemented from inception to 9 December 2021. All clinical studies that included women with breast cancer subjected to AeroForm-based tissue expansion for breast reconstruction were included in the study.
RESULTS
This systematic review included eleven articles consisting of 748 patients. There were 1220 reconstructed breasts in which 530 (43.44%) breasts were reconstructed using AeroForm devices. AeroForm-based tissue expanders were associated with shorter duration to complete breast expansion (MD-35.22; 95% -46.65, -23.78;P<0.001) and complete reconstruction (MD-30.511; 95% -54.659, -6.636;P=0.013). The overall satisfaction rate of the aesthetic results of the AeroForm expanders was 81.4% (95%CI; 60.3% to 92.6%,P=0.006) and 64.6% (95%CI; 53.8% to 74%,P=0.008) for patients and surgeons. Patients subjected to saline-based breast reconstruction were 1.17 times at high risk to develop breast-related adverse events (RR1.17; 95% 0.86, 1.58; P=0.31). This includes a high risk of mastectomy flap necrosis (RR1.91; 95% 1.03, 3.55;P=0.04) and post-operative wound infection (RR 1.63; 95% 0.91, 2.91;P=0.1).
CONCLUSION
AeroForm-based tissue expanders represent a new era of breast reconstruction. These devices provided an earlier transition to exchange for the permanent implant with a convenient and comfortable expansion process. This was associated with a high satisfaction rate for patients and surgeons.
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: Female; Humans; Tissue Expansion Devices; Mastectomy; Breast Neoplasms; Mammaplasty; Tissue Expansion; Retrospective Studies; Treatment Outcome; Breast Implants
PubMed: 35551440
DOI: 10.1007/s00266-022-02901-y -
Quality of Life Research : An... Jun 2016Bilateral prophylactic mastectomy (BPM) is effective in reducing the risk of breast cancer in women with a well-defined family history of breast cancer or in women with... (Review)
Review
PURPOSE
Bilateral prophylactic mastectomy (BPM) is effective in reducing the risk of breast cancer in women with a well-defined family history of breast cancer or in women with BRCA 1 or 2 mutations. Evaluating patient-reported outcomes following BPM are thus essential for evaluating success of BPM from patient's perspective. Our systematic review aimed to: (1) identify studies describing health-related quality of life (HRQOL) in patients following BPM with or without reconstruction; (2) assess the effect of BPM with or without reconstruction on HRQOL; and (3) identify predictors of HRQOL post-BPM.
METHODS
We performed a systematic review of literature using the PRISMA guidelines. PubMed, Embase, PsycINFO, Web of Science, Scopus and Cochrane databases were searched.
RESULTS
The initial search resulted in 1082 studies; 22 of these studies fulfilled our inclusion criteria. Post-BPM, patients are satisfied with the outcomes and report high psychosocial well-being and positive body image. Sexual well-being and somatosensory function are most negatively affected. Vulnerability, psychological distress and preoperative cancer distress are significant negative predictors of quality of life and body image post-BPM.
CONCLUSION
There is a paucity of high-quality data on outcomes of different HRQOL domains post-BPM. Future studies should strive to use validated and breast-specific PRO instruments for measuring HRQOL. This will facilitate shared decision-making by enabling surgeons to provide evidence-based answers to women contemplating BPM.
Topics: Adult; Body Image; Breast Neoplasms; Female; Humans; Mammaplasty; Middle Aged; Patient Reported Outcome Measures; Patient Satisfaction; Prophylactic Mastectomy; Quality of Life; Sexual Dysfunctions, Psychological
PubMed: 26577764
DOI: 10.1007/s11136-015-1181-6 -
The impact of breast reduction surgery on breastfeeding: Systematic review of observational studies.PloS One 2017Almost half a million breast reduction surgeries are performed internationally each year, yet it is unclear how this type of surgery impacts breastfeeding. This is... (Review)
Review
BACKGROUND
Almost half a million breast reduction surgeries are performed internationally each year, yet it is unclear how this type of surgery impacts breastfeeding. This is particularly important given the benefits of breastfeeding.
OBJECTIVES
To determine if breast reduction surgery impacts breastfeeding success and whether different surgical techniques differentially impact breast feeding success.
METHODS
Databases were searched up to September 5, 2017. Studies were included if they reported the number of women successful at breastfeeding or lactation after breast reduction surgery, and if they reported either the total number of women who had children following breast reduction surgery, or the total number of women who attempted to breastfeed following surgery.
RESULTS
Of 1,212 studies, 51 studies met the inclusion criteria; they were located worldwide and had 31 distinct breast reduction techniques. The percentage of breastfeeding success among studies was highly variable. However, when analyzed by the preservation of the column of parenchyma from the nipple areola complex to the chest wall (subareolar parenchyma), a clear pattern emerged. The median breastfeeding success was 4% (interquartile range (IQR) 0-38%) for techniques with no preservation, compared to 75% (IQR 37-100%) for techniques with partial preservation and 100% (IQR 75-100%) for techniques with full preservation.
CONCLUSIONS
Techniques that preserve the column of subareolar parenchyma appear to have a greater likelihood of successful breastfeeding. The preservation of the column of subareolar parenchyma should be disclosed to women prior to surgery. Guidelines on the best breast reduction techniques to be used in women of child bearing years may be advantageous to ensure women have the greatest potential for successful breastfeeding after breast reduction surgery.
Topics: Breast Feeding; Female; Humans; Mammaplasty
PubMed: 29049351
DOI: 10.1371/journal.pone.0186591 -
Scientific Reports Apr 2020Flap necrosis is a common complication after mastectomy, and nitroglycerin (NTG) ointment has been used successfully to treat it. However, it is not clear whether... (Meta-Analysis)
Meta-Analysis
Flap necrosis is a common complication after mastectomy, and nitroglycerin (NTG) ointment has been used successfully to treat it. However, it is not clear whether topical NTG can completely prevent the occurrence of flap necrosis after breast cancer surgery, and it is also unclear whether this treatment may cause side effects. Three randomized controlled trials (RCTs) and two retrospective cohort studies (RCSs) were included in our investigation. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We found that NTG significantly reduced the rates of mastectomy flap necrosis, full-thickness flap necrosis, and debridement as well as the rate of early complications other than flap necrosis. However, there was no significant difference in drug-related adverse reactions, explantation, superficial flap necrosis, infection, hematoma or seroma between the NTG and placebo groups.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mammary Glands, Human; Mastectomy; Middle Aged; Necrosis; Nitroglycerin; Ointments; Patient Safety; Seroma; Surgical Flaps; Treatment Outcome; Vasodilator Agents
PubMed: 32317705
DOI: 10.1038/s41598-020-63721-1 -
Annals of Surgical Oncology May 2014The specific aim of this study was to conduct a systematic review of the literature to assess outcomes data on complications and aesthetic results associated with... (Review)
Review
PURPOSE
The specific aim of this study was to conduct a systematic review of the literature to assess outcomes data on complications and aesthetic results associated with autologous tissue-based breast reconstruction performed before or after chest wall irradiation.
METHODS
Studies from a PubMed search that met predetermined inclusion criteria were identified. Complications of interest included partial or total flap loss, fat necrosis, thrombosis, infection, seroma, hematoma, delayed wound healing, and flap fibrosis/contracture. Pooled complication rates were calculated.
RESULTS
A total of 20 articles were included in the study for autologous reconstruction. These primary articles were selected after screening 897 publications, with six studies presenting data on pre-reconstruction radiation, nine studies presenting data on post-reconstruction radiation, and five studies presenting data on both patient groups. Comparison of pooled complication rates between flaps irradiated before or after reconstruction were statistically similar, including total flap loss (1 vs. 4 %), wound healing complications (10 vs. 14 %), infection (4 vs. 6 %), hematoma (2 vs. 1 %), seroma (4 vs. 4 %), and fat necrosis (10 vs. 13 %). The pooled rate of flap contracture and fibrosis was 27 % in flap reconstructions exposed to radiotherapy. Statistical evaluation of aesthetic outcomes was impossible as a result of variability in assessment and reporting methods.
CONCLUSIONS
Review of the current literature suggests similar rates of complications and success rates in autologous breast reconstruction patients exposed to pre- or post-reconstruction radiation. Immediate autologous reconstruction should be considered as a viable option even in patients who are likely to require postmastectomy radiotherapy.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Morbidity; Postoperative Complications; Practice Patterns, Physicians'; Prognosis; Reoperation
PubMed: 24473643
DOI: 10.1245/s10434-014-3494-z -
Journal of Plastic, Reconstructive &... Aug 2023Autologous breast reconstruction has become standard of care, but there is no consensus on prophylactic antibiotic regimens for this surgical procedure. This review aims... (Review)
Review
BACKGROUND
Autologous breast reconstruction has become standard of care, but there is no consensus on prophylactic antibiotic regimens for this surgical procedure. This review aims to present evidence on the best prophylactic antibiotic protocol to lower the risk of surgical site infections in autologous breast reconstructions.
METHODS
The search was performed in PubMed, EMBASE, Web of Science, and Cochrane Library on 25th of January 2022. Data on the number of surgical site infections, breast reconstruction type (pedicled or free flap) and reconstruction timing (immediate or delayed), as well as data on the type, dose, route of administration, timing, and duration of antibiotic treatment were extracted. All included articles were additionally assessed for potential risk of bias by using the revised RTI Item Bank tool.
RESULTS
12 studies were included in this review. No evidence is found that giving post-operative antibiotics for a prolonged period longer than 24 h after surgery is useful in lowering infection rates. This review could not distinguish between the best choice of antimicrobial agent.
DISCUSSION
Although this is the first study that collected current evidence on this topic, the quality of evidence is limited due to a small number of available studies (N = 12) with small study populations. The included studies have high heterogeneity, no adjustment for confounding, and interchangeably used definitions. Future research is highly recommended with predefined definitions, and a sufficient number of included patients.
CONCLUSION
Antibiotic prophylaxis up to a maximum of 24 h is useful in lowering infection rates in autologous breast reconstructions.
Topics: Humans; Antibiotic Prophylaxis; Surgical Wound Infection; Anti-Bacterial Agents; Mammaplasty
PubMed: 37307619
DOI: 10.1016/j.bjps.2023.04.038 -
The Cochrane Database of Systematic... Feb 2017Despite multi-modal analgesic techniques, acute postoperative pain remains an unmet health need, with up to three quarters of people undergoing surgery reporting... (Review)
Review
BACKGROUND
Despite multi-modal analgesic techniques, acute postoperative pain remains an unmet health need, with up to three quarters of people undergoing surgery reporting significant pain. Liposomal bupivacaine is an analgesic consisting of bupivacaine hydrochloride encapsulated within multiple, non-concentric lipid bi-layers offering a novel method of sustained-release analgesia.
OBJECTIVES
To assess the analgesic efficacy and adverse effects of liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain.
SEARCH METHODS
On 13 January 2016 we searched CENTRAL, MEDLINE, MEDLINE In-Process, Embase, ISI Web of Science and reference lists of retrieved articles. We obtained clinical trial reports and synopses of published and unpublished studies from Internet sources, and searched clinical trials databases for ongoing trials.
SELECTION CRITERIA
Randomised, double-blind, placebo- or active-controlled clinical trials in people aged 18 years or over undergoing elective surgery, at any surgical site, were included if they compared liposomal bupivacaine infiltration at the surgical site with placebo or other type of analgesia.
DATA COLLECTION AND ANALYSIS
Two review authors independently considered trials for inclusion, assessed risk of bias, and extracted data. We performed data analysis using standard statistical techniques as described in the Cochrane Handbook for Systematic Reviews of Interventions, using Review Manager 5.3. We planned to perform a meta-analysis and produce a 'Summary of findings' table for each comparison however there were insufficient data to ensure a clinically meaningful answer. As such we have produced two 'Summary of findings' tables in a narrative format. Where possible we assessed the quality of evidence using GRADE.
MAIN RESULTS
We identified nine studies (10 reports, 1377 participants) that met inclusion criteria. Four Phase II dose-escalating/de-escalating trials, designed to evaluate and demonstrate efficacy and safety, presented pooled data that we could not use. Of the remaining five parallel-arm studies (965 participants), two were placebo controlled and three used bupivacaine hydrochloride local anaesthetic infiltration as a control. Using the Cochrane tool, we judged most studies to be at unclear risk of bias overall; however, two studies were at high risk of selective reporting bias and four studies were at high risk of bias due to size (fewer than 50 participants per treatment arm).Three studies (551 participants) reported the primary outcome cumulative pain intensity over 72 hours following surgery. Compared to placebo, liposomal bupivacaine was associated with a lower cumulative pain score between the end of the operation (0 hours) and 72 hours (one study, very low quality). Compared to bupivacaine hydrochloride, two studies showed no difference for this outcome (very low quality evidence), however due to differences in the surgical population and surgical procedure (breast augmentation versus knee arthroplasty) we did not perform a meta-analysis.No serious adverse events were reported to be associated with the use of liposomal bupivacaine and none of the five studies reported withdrawals due to drug-related adverse events (moderate quality evidence).One study reported a lower mean pain score at 12 hours associated with liposomal bupivacaine compared to bupivacaine hydrochloride, but not at 24, 48 or 72 hours postoperatively (very low quality evidence).Two studies (382 participants) reported a longer time to first postoperative opioid dose compared to placebo (low quality evidence).Two studies (325 participants) reported the total postoperative opioid consumption over the first 72 hours: one study reported a lower cumulative opioid consumption for liposomal bupivacaine compared to placebo (very low quality evidence); one study reported no difference compared to bupivacaine hydrochloride (very low quality evidence).Three studies (492 participants) reported the percentage of participants not requiring postoperative opioids over initial 72 hours following surgery. One of the two studies comparing liposomal bupivacaine to placebo demonstrated a higher number of participants receiving liposomal bupivacaine did not require postoperative opioids (very low quality evidence). The other two studies, one versus placebo and one versus bupivacaine hydrochloride, found no difference in opioid requirement (very low quality evidence). Due to significant heterogeneity between the studies (I = 92%) we did not pool the results.All the included studies reported adverse events within 30 days of surgery, with nausea, constipation and vomiting being the most common. Of the five parallel-arm studies, none performed or reported health economic assessments or patient-reported outcomes other than pain.Using GRADE, the quality of evidence ranged from moderate to very low. The major limitation was the sparseness of data for outcomes of interest. In addition, a number of studies had a high risk of bias resulting in further downgrading.
AUTHORS' CONCLUSIONS
Liposomal bupivacaine at the surgical site does appear to reduce postoperative pain compared to placebo, however, at present the limited evidence does not demonstrate superiority to bupivacaine hydrochloride. There were no reported drug-related serious adverse events and no study withdrawals due to drug-related adverse events. Overall due to the low quality and volume of evidence our confidence in the effect estimate is limited and the true effect may be substantially different from our estimate.
Topics: Anesthetics, Local; Arthroplasty, Replacement, Knee; Bupivacaine; Humans; Liposomes; Mammaplasty; Pain Measurement; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 28146271
DOI: 10.1002/14651858.CD011419.pub2 -
Breast Cancer Research and Treatment Sep 2015Adjuvant chemotherapy is often needed to achieve adequate breast cancer control. The increasing popularity of immediate breast reconstruction (IBR) raises concerns that... (Meta-Analysis)
Meta-Analysis Review
Adjuvant chemotherapy is often needed to achieve adequate breast cancer control. The increasing popularity of immediate breast reconstruction (IBR) raises concerns that this procedure may delay the time to adjuvant chemotherapy (TTC), which may negatively impact oncological outcome. The current systematic review aims to investigate this effect. During October 2014, a systematic search for clinical studies was performed in six databases with keywords related to breast reconstruction and chemotherapy. Eligible studies met the following inclusion criteria: (1) research population consisted of women receiving therapeutic mastectomy, (2) comparison of IBR with mastectomy only groups, (3) TTC was clearly presented and mentioned as outcome measure, and (4) original studies only (e.g., cohort study, randomized controlled trial, case-control). Fourteen studies were included, representing 5270 patients who had received adjuvant chemotherapy, of whom 1942 had undergone IBR and 3328 mastectomy only. One study found a significantly shorter mean TTC of 12.6 days after IBR, four studies found a significant delay after IBR averaging 6.6-16.8 days, seven studies found no significant difference in TTC between IBR and mastectomy only, and two studies did not perform statistical analyses for comparison. In studies that measured TTC from surgery, mean TTC varied from 29 to 61 days for IBR and from 21 to 60 days for mastectomy only. This systematic review of the current literature showed that IBR does not necessarily delay the start of adjuvant chemotherapy to a clinically relevant extent, suggesting that in general IBR is a valid option for non-metastatic breast cancer patients.
Topics: Antineoplastic Combined Chemotherapy Protocols; Breast Neoplasms; Chemotherapy, Adjuvant; Female; Humans; Mammaplasty; Mastectomy; Time Factors; Treatment Outcome
PubMed: 26285643
DOI: 10.1007/s10549-015-3539-4