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Journal of Plastic, Reconstructive &... Apr 2018Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic... (Meta-Analysis)
Meta-Analysis
Perforator mapping reduces the operative time of DIEP flap breast reconstruction: A systematic review and meta-analysis of preoperative ultrasound, computed tomography and magnetic resonance angiography.
BACKGROUND
Prior to DIEP flap breast reconstruction, mapping the perforators of the lower abdominal wall using ultrasound, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) reduces the risk of flap failure. This review aimed to investigate the additional potential benefit of a reduction in operating time.
METHODS
We systematically searched the literature for studies concerning adult women undergoing DIEP flap breast reconstruction, which directly compared the operating times and adverse outcomes for those with and without preoperative perforator mapping by ultrasound, CTA or MRA. Outcomes were extracted, data meta-analysed and the quality of the evidence appraised.
RESULTS
Fourteen articles were included. Preoperative perforator mapping by CTA or MRA significantly reduced operating time (mean reduction of 54 minutes [95% CI 3, 105], p = 0.04), when directly compared to DIEP flap breast reconstruction with no perforator mapping. Further, perforator mapping by CTA was superior to ultrasound, as CTA saved more time in theatre (mean reduction of 58 minutes [95% CI 25, 91], p < 0.001) and was associated with a lower risk of partial flap failure (RR 0.15 [95% CI 0.04, 0.6], p = 0.007). All studies were at risk of methodological bias and the quality of the evidence was very low.
CONCLUSIONS
The quality of research regarding perforator mapping prior to DIEP flap breast reconstruction is poor and although preoperative angiography appears to save operative time, reduce morbidity and confer cost savings, higher quality research is needed.
REGISTRATION
PROSPERO ID CRD42017065012.
Topics: Abdominal Wall; Computed Tomography Angiography; Epigastric Arteries; Female; Humans; Magnetic Resonance Angiography; Mammaplasty; Operative Time; Perforator Flap; Ultrasonography, Mammary
PubMed: 29289500
DOI: 10.1016/j.bjps.2017.12.012 -
Plastic and Reconstructive Surgery Jan 2024Breast implants are the most commonly used medical devices in plastic surgery, and capsular contracture (CC) is one of the most common complications. However, our...
BACKGROUND
Breast implants are the most commonly used medical devices in plastic surgery, and capsular contracture (CC) is one of the most common complications. However, our assessment of CC is based largely on Baker grade, which is problematically subjective and affords only four possible values.
METHODS
The authors performed a systematic review concluding in September of 2021 in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. It identified 19 articles that propose approaches to measuring CC.
RESULTS
In addition to Baker grade, the authors identified several modalities reported to measure CC. These included magnetic resonance imaging, ultrasonography, sonoelastography, mammacompliance measuring devices, applanation tonometry, histologic evaluation, and serology. Capsule thickness and other measures of CC inconsistently correlated with Baker grade, whereas the presence of synovial metaplasia was consistently associated with Baker grade I and II, but not III and IV capsules.
CONCLUSIONS
There remains no particular method to reliably and specifically measure the contracture of capsules that form around breast implants. As such, we would recommend that research investigators use more than one modality to measure CC. Other variables that can impact breast implant stiffness and associated discomfort beyond CC need to be considered when evaluating patient outcomes. Given the value placed on CC outcomes in assessing breast implant safety, and the prevalence of breast implants overall, the need for a more reliable approach to measuring this outcome persists.
Topics: Humans; Consensus; Breast Implants; Breast Implantation; Breast; Contracture; Implant Capsular Contracture
PubMed: 37075286
DOI: 10.1097/PRS.0000000000010573 -
Medicina (Kaunas, Lithuania) May 2019: In those undergoing treatment for breast cancer, evidence has demonstrated a significant improvement in survival, and a reduction in the risk of local recurrence in...
: In those undergoing treatment for breast cancer, evidence has demonstrated a significant improvement in survival, and a reduction in the risk of local recurrence in patients who undergo postmastectomy radiation therapy (PMRT). There is uncertainty about the optimal timing of PMRT, whether it should be before or after tissue expander or permanent implant placement. This study aimed to summarize the data reported in the literature on the effect of the timing of PMRT, both preceding and following 2-stage expander-implant breast reconstruction (IBR), and to statistically analyze the impact of timing on infection rates and the need for explantation. : A comprehensive systematic review of the literature was conducted using the PubMed/Medline, Ovid, and Cochrane databases without timeframe limitations. Articles included in the analysis were those reporting outcomes data of PMRT in IBR published from 2009 to 2017. Chi-square statistical analysis was performed to compare infection and explantation rates between the two subgroups at < 0.05. : A total of 11 studies met the inclusion criteria for this study. These studies reported outcomes data for 1565 total 2-stage expander-IBR procedures, where PMRT was used (1145 before, and 420 after, implant placement). There was a statistically significant higher likelihood of infection following pre-implant placement PMRT (21.03%, = 0.000079), compared to PMRT after implant placement (9.69%). There was no difference in the rate of explantation between pre-implant placement PMRT (12.93%) and postimplant placement PMRT (11.43%). : This study suggests that patients receiving PMRT before implant placement in 2-stage expander-implant based reconstruction may have a higher risk of developing an infection.
Topics: Adult; Breast Implantation; Breast Neoplasms; Chi-Square Distribution; Female; Humans; Mammaplasty; Mastectomy; Radiotherapy; Time Factors; Treatment Outcome
PubMed: 31146506
DOI: 10.3390/medicina55060226 -
The Cochrane Database of Systematic... Apr 2020Breast cancer will affect one in eight women during their lifetime. The opportunity to restore the removed tissue and cosmetic appearance is provided by reconstructive... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Breast cancer will affect one in eight women during their lifetime. The opportunity to restore the removed tissue and cosmetic appearance is provided by reconstructive breast surgery following skin-sparing mastectomy (SSM). Mastectomy skin flap necrosis (MSFN) is a common complication following SSM breast reconstruction. This postoperative complication can be prevented by intraoperative assessment of mastectomy skin flap viability and intervention when tissue perfusion is compromised. Indocyanine green fluorescence angiography is presumed to be a better predictor of MSFN compared to clinical evaluation alone.
OBJECTIVES
To assess the effects of indocyanine green fluorescence angiography (ICGA) for preventing mastectomy skin flap necrosis in women undergoing immediate breast reconstruction following skin-sparing mastectomy. To summarise the different ICGA protocols available for assessment of mastectomy skin flap perfusion in women undergoing immediate breast reconstructions following skin-sparing mastectomy.
SEARCH METHODS
We searched the Cochrane Breast Cancer Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL; Issue 3, 2019), MEDLINE, Embase, the World Health Organization's International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov in April 2019. In addition, we searched reference lists of published studies.
SELECTION CRITERIA
We included studies that compared the use of ICGA to clinical evaluation to assess mastectomy skin vascularisation and recruited women undergoing immediate autologous or prosthetic reconstructive surgery following SSM for confirmed breast malignancy or high risk of developing breast cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the risk of bias of the included nonrandomised studies and extracted data on postoperative outcomes, including postoperative MSFN, reoperation, autologous flap necrosis, dehiscence, infection, haematoma and seroma, and patient-related outcomes. The quality of the evidence was assessed using the GRADE approach and we constructed two 'Summary of finding's tables: one for the comparison of ICGA to clinical evaluation on a per patient basis and one on a per breast basis.
MAIN RESULTS
Nine nonrandomised cohort studies met the inclusion criteria and involved a total of 1589 women with 2199 breast reconstructions. We included seven retrospective and two prospective cohort studies. Six studies reported the number of MSFN on a per breast basis for a total of 1435 breasts and three studies reported the number of MSFN on a per patient basis for a total of 573 women. Five studies reported the number of other complications on a per breast basis for a total of 1370 breasts and four studies reported the number on a per patient basis for a total of 613 patients. Therefore, we decided to pool data separately. Risk of bias for each included nonrandomised study was assessed using the Newcastle-Ottawa Scale for cohort studies. There was serious concern with risk of bias due to the nonrandomised study design of all included studies and the low comparability of cohorts in most studies. The quality of the evidence was found to be very low, after downgrading the quality of evidence twice for imprecision based on the small sample sizes and low number of events in the included studies. Postoperative complications on a per patient basis We are uncertain about the effect of ICGA on MSFN (RR 0.79, 95% CI 0.40 to 1.56; three studies, 573 participants: very low quality of evidence), infection rates (RR 0.91, 95% CI 0.60 to 1.40; four studies, 613 participants: very low quality of evidence), haematoma rates (RR 0.87, 95% CI 0.30 to 2.53; two studies, 459 participants: very low quality of evidence) and seroma rates (RR 1.68, 95% CI 0.41 to 6.80; two studies, 408 participants: very low quality of evidence) compared to the clinical group. We found evidence that ICGA may reduce reoperation rates (RR 0.50, 95% CI 0.35 to 0.72; four studies, 613 participants: very low quality of evidence). One study considered dehiscence as an outcome. In this single study, dehiscence was observed in 2.2% of participants (4/184) in the ICGA group compared to 0.5% of participants (1/184) in the clinical group (P = 0.372). The RR was 4.00 (95% CI 0.45 to 35.45; one study; 368 participants; very low quality of evidence). Postoperative complications on a per breast basis We found evidence that ICGA may reduce MSFN (RR 0.62, 95% CI 0.48 to 0.82; six studies, 1435 breasts: very low quality of evidence), may reduce reoperation rates (RR 0.65, 95% CI 0.47 to 0.92; five studies, 1370 breasts: very low quality of evidence) and may reduce infection rates (RR 0.65, 95% CI 0.44 to 0.97; five studies, 1370 breasts: very low quality of evidence) compared to the clinical group. We are uncertain about the effect of ICGA on haematoma rates (RR 1.53, CI 95% 0.47 to 4.95; four studies, 1042 breasts: very low quality of evidence) and seroma rates (RR 0.71, 95% CI 0.37 to 1.35; two studies, 528 breasts: very low quality of evidence). None of the studies reported patient-related outcomes. ICGA protocols: eight studies used the SPY System and one study used the Photodynamic Eye imaging system (PDE) to assess MSFN. ICGA protocols in the included studies were not extensively described in most studies.
AUTHORS' CONCLUSIONS
Although mastectomy skin flap perfusion is performed more frequently using ICGA as a helpful tool, there is a lack of high-quality evidence in the context of randomised controlled trials. The quality of evidence in this review is very low, since only nonrandomised cohort studies have been included. With the results from this review, no conclusions can be drawn about what method of assessment is best to use during breast reconstructive surgery. High-quality randomised controlled studies that compare the use of ICGA to assess MSFN compared to clinical evaluation are needed.
Topics: Angiography; Bias; Breast Neoplasms; Coloring Agents; Female; Hematoma; Humans; Indocyanine Green; Mammaplasty; Mastectomy; Necrosis; Postoperative Complications; Prospective Studies; Reoperation; Retrospective Studies; Seroma; Surgical Flaps; Surgical Wound Dehiscence; Surgical Wound Infection
PubMed: 32320056
DOI: 10.1002/14651858.CD013280.pub2 -
Annals of Surgical Oncology Jan 2024Breast reconstruction (BR) is routinely offered to restore symmetry after mastectomy for breast cancer. Not all women, however, may want reconstructive surgery. A... (Review)
Review
BACKGROUND
Breast reconstruction (BR) is routinely offered to restore symmetry after mastectomy for breast cancer. Not all women, however, may want reconstructive surgery. A contralateral mastectomy (CM) to achieve "flat symmetry" can be an excellent alternative, but surgeons are often reluctant to offer this procedure. This systematic review aimed to summarize the available evidence regarding the outcomes of CM as the first step to developing guidelines in this area.
METHODS
PubMed, MEDLINE, CINAHL and PsycINFO were searched to identify primary research studies, published in English between 1 January 2000 and 30 August 2022, evaluating clinical or patient-reported outcomes for women who underwent a CM without reconstruction after a mastectomy for unilateral breast cancer. Simple descriptive statistics summarized quantitative data, and content analysis was used for qualitative data.
RESULTS
The study included 15 studies (13 quantitative, 1 qualitative, and 1 mixed-methods) evaluating outcomes for at least 1954 women who underwent a bilateral mastectomy without reconstruction (BM) after unilateral breast cancer. The risk of surgical complications after BM was higher than after unilateral mastectomy without reconstruction (UM) but significantly less than after BR. Satisfaction with the decision for BM was high in all the studies. Key themes relating to flat denial, stigma, and gender-based assumptions were identified.
CONCLUSION
Women electing to undergo BM reported high levels of satisfaction with their decision and complication rates similar to those for UM. Further study is needed to comprehensively explore the outcomes for women seeking BM, but these data should give surgeons confidence to offer the procedure as an alternative option for symmetry after unilateral mastectomy for breast cancer.
REGISTRATION
This systematic review was prospectively registered on the PROSPERO database (CRD42022353689).
Topics: Female; Humans; Mastectomy; Breast Neoplasms; Unilateral Breast Neoplasms; Mammaplasty; Mastectomy, Simple
PubMed: 37749407
DOI: 10.1245/s10434-023-14294-6 -
BMC Anesthesiology Nov 2020Breast surgery in the United States is common. Pain affects up to 50% of women undergoing breast surgery and can interfere with postoperative outcomes. General...
What is the role of locoregional anesthesia in breast surgery? A systematic literature review focused on pain intensity, opioid consumption, adverse events, and patient satisfaction.
BACKGROUND
Breast surgery in the United States is common. Pain affects up to 50% of women undergoing breast surgery and can interfere with postoperative outcomes. General anesthesia is the conventional, most frequently used anaesthetic technique. Various locoregional anesthetic techniques are also used for breast surgeries. A systematic review of the use of locoregional anesthesia for postoperative pain in breast surgery is needed to clarify its role in pain management.
OBJECTIVES
To systematically review literature to establish the efficacy and the safety of locoregional anesthesia used in the treatment of pain after breast surgery.
METHODS
Embase, MEDLINE, Google Scholar and Cochrane Central Trials Register were systematically searched in Mars 2020 for studies examining locoregional anesthesia for management of pain in adults after breast surgery. The methodological quality of the studies and their results were appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and specific measurement properties criteria, respectively.
RESULTS
Nineteen studies evaluating locoregional anesthesia were included: 1058 patients underwent lumpectomy/mastectomy, 142 breast augmentation and 79 breast reduction. Locoregional anesthesia provides effective anesthesia and analgesia in the perioperative setting, however no statistically significant difference emerged if compared to other techniques. For mastectomy only, the use of locoregional techniques reduces pain in the first hour after the end of the surgery if compared to other procedures (p = 0.02). Other potentially beneficial effects of locoregional anesthesia include decreased need for opioids, decreased postoperative nausea and vomiting, fewer complications and increased patient satisfaction. All this improves postoperative recovery and shortens hospitalization stay. In none of these cases, locoregional anesthesia was statistically superior to other techniques.
CONCLUSION
The results of our review showed no differences between locoregional anesthesia and other techniques in the management of breast surgery. Locoregional techniques are superior in reducing pain in the first hour after mastectomy.
Topics: Analgesics, Opioid; Anesthesia, Conduction; Anesthesia, Local; Breast; Female; Humans; Mammaplasty; Mastectomy; Pain, Postoperative; Patient Satisfaction
PubMed: 33225913
DOI: 10.1186/s12871-020-01206-4 -
International Journal of Molecular... Mar 2024There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell... (Review)
Review
There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell carcinoma (BIA-SCC) has received limited scholarly attention since its first case in 1992. Thus, this study aims to conduct a qualitative synthesis focused on the underexplored association between breast implants and BIA-SCC. A systematic review was conducted utilizing the PubMed, Web of Science, and Cochrane databases to identify all currently reported cases of BIA-SCC. Additionally, a literature review was performed to identify potential biochemical mechanisms that could lead to BIA-SCC. Studies were vetted for quality using the NIH quality assessment tool. From an initial pool of 246 papers, 11 met the quality criteria for inclusion, examining a total of 14 patients aged between 40 and 81 years. BIA-SCC was found in a diverse range of implants, including those with smooth and textured surfaces, as well as those filled with saline and silicone. The condition notably manifested a proclivity for aggressive clinical progression, as evidenced by a mortality rate approximating 21.4% within a post-diagnostic interval of six months. Our literature review reveals that chronic inflammation, driven by various external factors such as pathogens and implants, can initiate carcinogenesis through epigenetic modifications and immune system alterations. This includes effects from exosomes and macrophage polarization, showcasing potential pathways for the pathogenesis of BIA-SCC. The study highlights the pressing need for further investigation into BIA-SCC, a subject hitherto inadequately addressed in the academic sphere. This necessitates the urgency for early screening and intervention to improve postoperative outcomes. While the review is confined by its reliance on case reports and series, it serves as a valuable reference for future research endeavors.
Topics: Humans; Adult; Middle Aged; Aged; Aged, 80 and over; Female; Breast Implants; Breast Implantation; Mammaplasty; Breast Neoplasms; Lymphoma, Large-Cell, Anaplastic
PubMed: 38474119
DOI: 10.3390/ijms25052872 -
Journal of Plastic Surgery and Hand... Jan 2024There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic...
BACKGROUND
There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies.
METHODS
Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting.
RESULTS AND CONCLUSIONS
A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.
Topics: Cost-Benefit Analysis; Databases, Factual; Mammaplasty; Mastectomy; Perforator Flap; Humans
PubMed: 38189784
DOI: 10.2340/jphs.v59.19649 -
Medicine Feb 2023The efficacy of pectoral nerve block for pain control remains unknown in patients undergoing breast augmentation. This meta-analysis aims to explore the analgesic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The efficacy of pectoral nerve block for pain control remains unknown in patients undergoing breast augmentation. This meta-analysis aims to explore the analgesic efficacy of pectoral nerve block for breast augmentation.
METHODS
We systematically searched PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and included randomized controlled trials reporting pectoral nerve block versus no block for breast augmentation.
RESULTS
Five randomized controlled trials were included in this meta-analysis. Compared with control group after breast augmentation, pectoral nerve block was associated with substantially reduced pain scores at 1 hour (standard mean difference [SMD] = -1.63; 95% confidence interval [CI] = -2.81 to -0.44; P = .007), maximal pain scores at 1 to 6 hours (SMD = -1.72; 95% CI = -2.75 to -0.69; P = .001) and 6 to 24 hours (SMD = -2.06; 95% CI = -3.40 to -0.72; P = .003), rescue analgesic (odd ratio = 0.17; 95% CI = 0.05-0.57; P = .004), nausea (SMD = 0.21; 95% CI = 0.08-0.54; P = .001), and vomiting (odd ratio = 0.15; 95% CI = 0.05-0.39; P = .0001).
CONCLUSIONS
Pectoral nerve block benefits to alleviate pain intensity after breast augmentation.
Topics: Humans; Pain Management; Nerve Block; Mammaplasty; Thoracic Nerves; Pain; Pain, Postoperative
PubMed: 36827054
DOI: 10.1097/MD.0000000000032863 -
World Neurosurgery Jan 2024Ventriculoperitoneal shunt is one of the most common neurosurgical procedures in the treatment of hydrocephalus. There are reports of migration of the distal catheter to...
BACKGROUND
Ventriculoperitoneal shunt is one of the most common neurosurgical procedures in the treatment of hydrocephalus. There are reports of migration of the distal catheter to the breast pocket where cerebrospinal fluid then collects and can develop into a pseudocyst. There exist case reports in the literature of patients with prior breast augmentation who present with distal catheter migration from the peritoneal space into the breast tissue. We present a case series of 3 patients with preexisting breast augmentation who returned with unilateral breast enlargement after ventriculoperitoneal shunt. In all 3 patients, the distal catheter migrated out of the peritoneal space and was found to be coiled around the breast prosthesis. Additionally, we offer recommendations for managing these complications and a review of the literature.
METHODS
We performed a systematic review without meta-analysis of studies involving management of shunt migration in the setting of preexisting breast implants. We present a case series of 3 patients whom we treated with breast cerebrospinal pseudocyst after migration of the distal catheter into the breast tissue.
RESULTS
A total of 17 studies, dating from 2002 to 2022, met our inclusion and exclusion criteria and were selected for full review. Catheter migration occurred between 2 weeks and 9 months of initial shunt placement. All patients presented with unilateral breast enlargement and cerebrospinal fluid pseudocyst formation. All patients underwent revision shunt surgery. Surgical treatment strategies used included reimplantation of the distal catheter into the pleural space or ipsilateral or contralateral peritoneal space or complete removal of the entire shunt system.
CONCLUSIONS
Breast-related ventriculoperitoneal shunt complication is a rare entity that is increasingly seen as more patients receive breast augmentation. Breast-related shunt complications most commonly present with cerebrospinal fluid pseudocyst formation in the breast. It is important for neurosurgeons to be aware of an underlying breast implant before placing a ventriculoperitoneal shunt. For patients who have migration of the distal catheter into the breast, a protocol for managing these situations should be followed to ensure no shunt infection and avoidance of future catheter migration complications with subsequent shunt revisions.
Topics: Humans; Ventriculoperitoneal Shunt; Mammaplasty; Breast Implants; Hydrocephalus; Postoperative Complications; Cysts; Iatrogenic Disease; Cerebrospinal Fluid Shunts; Breast; Hypertrophy
PubMed: 37898269
DOI: 10.1016/j.wneu.2023.10.120