Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre.

INTRODUCTION: Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. METHODS: A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. RESULTS: A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). CONCLUSION: This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

Implications of abnormal abdominal wall computed tomographic angiography findings on postmastectomy free flap breast reconstruction.

BACKGROUND: Preoperative computed tomography angiography (CTA) of the abdominal wall vessels is used when planning free flap breast reconstruction (FFBR) because it provides a surgical road map which facilitates flap harvest. However, there are few reports on the effect of abnormal findings on the operative plan. METHODS: We conducted a retrospective study of all FFBRs performed at a tertiary referral center over a 6-year period (November 2011 to June 2017). One consultant radiologist reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected. RESULTS: Two hundred patients received preoperative CTAs. Fourteen percent of patients (n=28) had abnormal findings. Of these findings, 18% were vascular anomalies; 36% tumorrelated and 46% were "miscellaneous." In four patients, findings subsequently prevented surgery; they comprised a mesenteric artery aneurysm, absent deep inferior epigastric (DIE) vessels, bilateral occluded DIE arteries, and significant bone metastases. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled transverse rectus abdominis musculocutaneous flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of FFBR. More than one in 10 of those with abnormal findings went on to have further imaging before their operation. CONCLUSIONS: CTA in FFBR can have a wider impact than facilitating surgical planning and reducing operative times. Incidental findings can influence the surgical plan, and in some instances, avoid doomed-to-fail and unsafe surgery. It is therefore important that these scans are reported by an experienced radiologist.

Trends in post-mastectomy breast reconstruction types at a breast cancer tertiary referral centre before and after introduction of acellular dermal matrices.

BACKGROUND: Reconstructive breast surgery has continued to evolve over the last decade with a key change being the adoption of acellular dermal matrices (ADMs) as an adjunct for implant-based procedures. This retrospective observational study assesses the effect of ADMs on post-mastectomy reconstructive practice performed in a single institution. METHODS: We conducted a review of all patients undergoing breast reconstruction at a University Teaching Hospital for an 18-month period before and after adopting ADMs. Demographic, procedural and complication data for these two cohorts were compared (χ2 and Student's t-tests). RESULTS: A total of 264 women (336 breasts), mean age 47.5 years, were identified: 137 before and 127 after the introduction of ADM. Implant-only reconstructions increased from 16% to 52% following the adoption of ADM (p < 0.01), whereas the proportion of both latissimus dorsi and deep inferior epigastric perforator flap reconstructions decreased significantly (31%-11% and 49%-34%, respectively, p < 0.01). The rate of early complications for the implant-only procedures was not significantly different with or without ADM (26% versus 20%, respectively, p = 0.44), despite there being no difference in the rate of adjuvant radiotherapy (22% versus 35%, respectively, p = 0.30). CONCLUSIONS: This study showed that since ADM introduction to our centre, more breast reconstructions have been of the implant-only type with consequent reductions in the more complex and expensive autologous techniques. Implant-only procedures that incorporated ADM use had similar complication rates to those that did not.

A direct comparison of porcine (Strattice™) and bovine (Surgimend™) acellular dermal matrices in implant-based immediate breast reconstruction.

INTRODUCTION: Acellular dermal matrix (ADM) assisted implant-based breast reconstruction (IBBR) has grown in popularity over traditional submuscular techniques. Numerous human, bovine or porcine derived ADMs are available with the type used varying considerably worldwide. Yet, comparative evidence for the efficacy of different ADMs particularly xenogenic is limited. This study directly compares early outcomes of porcine (Strattice™) and bovine (Surgimend™) ADMs in IBBR. METHOD: Retrospective study of sequential experience of immediate IBBR using Strattice or Surgimend ADM. Data was collected for patients undergoing ADM assisted IBBR after prophylactic or therapeutic mastectomy in Cambridge (October 2011-March 2016). Patient demographics, adjuvant and neoadjuvant therapies, operative details, postoperative management and outcomes were analysed. KEY RESULTS: Total of 81 patients underwent IBBR with ADM; 38 bilateral and 43 unilateral (n = 119 breasts). Strattice was used in 30 breasts (25%) and Surgimend in 89 (75%). Analysis of patient specific variables showed statistical significance only for higher mastectomy weight in the Strattice group (367.1 ± 159.3 g versus 296.3 ± 133.4 g; P = 0.0379). Strattice was associated with higher rates of skin erythema post-operatively (16.7% versus 4.5%; P = 0.044). Analysed per woman or per breast, there was no statistically significant difference in rates of haematoma, infection, wound dehiscence, skin necrosis or seroma, although there was a trend towards more complications with Strattice. CONCLUSION: This study found significantly higher rates of skin erythema and a trend towards higher complication rates with Strattice in IBBR. Randomised controlled trials comparing different ADM outcomes are needed to inform best practice.

Back to basics: a case series of angular dermoid cyst excision.

Angular dermoid cysts are common peri-orbital tumours in children. Characteristically benign and slow growing, they are tumours of embryonic origin that arise along bony sutures as a result of abnormal ectodermal sequestration during development. Early surgical excision is recommended and performed in the majority of cases, particularly to restore facial cosmesis. We present a review of 25 cases, managed by our unit over the past 9 years, which underwent surgical excision by a single-stage procedure using the superior eyelid crease approach only. We show that despite the evolution of many techniques, including endoscopy, the superior eyelid crease remains superior in our opinion, affording simple complete excision with a well-concealed scar. Therefore, we recommend this technique as the optimal technique for lateral eyebrow dermoid cyst excision.

Multidisciplinary surgical management of cherubism complicated by neurofibromatosis type 1.

UNLABELLED: Cherubism is a rare, autosomal dominant, mostly self-limiting disease of the jaw. It is characterized by bilateral fibrous tissue hyperplasia, giant cell proliferation, and bony degeneration in the lower facial skeleton, which can result in a massive and severely deforming prominence of the maxillomandibular structure. This case study examines the multidisciplinary management of a severe case of cherubism complicated by neurofibromatosis type 1, 2 codominant nonsegregating conditions that were clinically and genetically diagnosed, an extremely rare combination. Adequate mandibular reduction, reconstruction, and dental implantation afforded good restoration of oral function as well as a marked aesthetic improvement. METHODS: A 14-year-old Fijian girl was referred to our unit for management of severe overgrowth of her mandible that compromised her speech and deglutition. In addition, she displayed clinical features consistent with neurofibromatosis type 1. Radiologic, histologic, and genetic analyses confirmed the diagnosis of both conditions. Our craniofacial multidisciplinary team undertook mandibular reconstruction followed by placement of osseointegrated dental implants. RESULTS: Mandibular reduction, reconstruction, and dental implantation resulted in a significantly improved functional and aesthetic outcome with no further regrowth at 3-year follow-up when she returned to the United Kingdom for osseointegrated dental implant insertion. CONCLUSIONS: The successful outcome of this surgically challenging, grossly disfiguring, and rare condition was largely a result of the combined input from our multidisciplinary team, adequate preoperative planning, and the use of a novel surgical technique in debulking and reconstructing her mandible.

Surgical management of two complex cases of large juvenile orbital ossifying fibroma.

Ossifying fibroma is a rare benign tumour of the craniofacial skeleton, which can have an aggressive biological behaviour in the paediatric population. Complete surgical excision, where possible, is the ideal. This case report discusses the multidisciplinary, surgical management of two complex cases of large juvenile ossifying fibroma (JOF), involving the orbit. Both patients underwent resection of the orbital ossifying fibroma with no macroscopic evidence of recurrence at 4 years follow-up. Full functional outcome was achieved with preservation of vision and facial nerve function as well as good facial symmetry and aesthetics. The successful surgical outcome of these cases was due to a combination of a multidisciplinary team approach, rigorous pre-operative planning, maximal tumour resection, and the use of a novel surgical technique involving a medial zygomatic-orbito-maxillary rotational osteotomy.