Reverse Abdominoplasty for Mastectomy Defect Closure in Advanced Breast Cancer.

BACKGROUND: Breast cancer patients with locally advanced breast cancer who require radical mastectomy are left with large chest wall defects. This poses a significant reconstructive challenge as many high-risk patients require timely postmastectomy adjuvant therapy. While the reverse abdominoplasty technique is commonly used for aesthetic improvement of the anterior trunk, it can be also be effectively used for closure of extensive mastectomy defects in this patient population. METHODS: We conducted a retrospective cohort study of all consecutive patients who underwent an extensive radical mastectomy followed by immediate closure with the reverse abdominoplasty technique at a single tertiary cancer center from June 2017 to July 2022. Patients who had concurrent skin grafting or breast mound flap reconstruction were excluded. Demographic, medical, oncologic, and reconstructive data were collected. RESULTS: Six patients were treated with reverse abdominoplasty for 9 chest wall defects after surgical excision of locally advanced breast cancer. The median tumor size was 10.7 cm (range, 6.7-10 cm) and the median mastectomy weight was 865.7 g (range, 356.4-1247.7 g). On average, the operation length was 191 minutes (range, 86-257 minutes) and the postoperative length of stay was 2.2 days (range, 1-5 days). All patients underwent systemic adjuvant therapy and the median time from surgery to initiation of therapy was 44.5 days (range, 32-75 days). CONCLUSIONS: Reverse abdominoplasty is a simple and safe technique to reliably close large defects after locally advanced breast cancer excision. It has a short operative time, hospital stay, and turnaround time to initiation of adjuvant therapy.

A Simple Technique to Correct Lumpectomy Deformities Using Free Nipple Grafting.

BACKGROUND: Lumpectomy followed by radiation can lead to severe breast asymmetry. Many surgeons are hesitant to perform traditional mastopexies on irradiated breasts due to increased complication rates. An alternative approach to achieve breast symmetry is presented. This technique consists of free nipple-areola complex (NAC) grafting of the irradiated breast to a higher position and primary closure of the donor site, in an appropriate fashion without undermining, followed by a formal mastopexy of the nonradiated breast. OBJECTIVE: To evaluate the outcomes of free NAC grafting, used as an alternative method to achieve breast symmetry, in patients who underwent lumpectomy with radiation. METHODS: A case series of 5 patients who underwent breast revision using this technique, performed by a single surgeon from 2017 to 2019 (n = 5), is presented. PATIENT DEMOGRAPHICS: All patients had history of lumpectomy followed by radiation therapy. The average age was 59.2 years, average BMI was 33.0. Three of 5 patients had a significant smoking history. The average time between radiation and surgery was 5.9 years. RESULTS: The average operating time was 141.8 minutes. The average follow-up period was 5.8 months. Two (40%) of the free NAC grafts were complicated by hypopigmentation of the reconstructed NAC. No major complications were reported, and no patients required return to the operating room. All patients had successful outcomes with improved breast symmetry. CONCLUSIONS: Free NAC grafting of irradiated breasts and contralateral mastopexy may be a reliable alternative to achieve breast symmetry, with a less invasive approach, in patients who underwent lumpectomy and radiation.

Abdominal Plication for Better Cosmetic Outcomes During Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Deep inferior epigastric perforator flap (DIEP) for breast reconstruction is a widely accepted technique for breast reconstruction. Secondary benefit of this technique is abdominal contour improvement. Because of direct access, abdominal plication can be performed at the time of abdominal closure. Our goal was to investigate if this addition affected the complications. METHODS: A retrospective chart review was performed on all DIEP flap reconstructions performed by a single surgeon at a cancer center, from March 2011 through February 2020. Presence of abdominal plication, age, and body mass index were compared with reoperation due to abdominal wound or hernia, procedure length in minutes, and length of stay. The association between the dependent and independent variables for the unadjusted and adjusted analysis was performed using the binary logistic regression analysis. RESULTS: Three hundred fifty-eight DIEP flaps performed on 233 patients for breast reconstruction were analyzed. Flap loss was 1.7%. Abdominal plication was performed in 178 flaps (49.7%) and not performed in 180 flaps (50.3%). Thirty-nine percent were immediate; 61% were delayed. The results did not show a statistically significant association between abdominal plication and the need to reoperate (P = 0.3). Results from the adjusted analysis (age, body mass index) also did not show a significant association between the plication, need to reoperate, procedure duration, or hospital stay (P = 0.4). CONCLUSIONS: Abdominal plication can improve cosmetic outcomes without increasing the duration of surgery, hospital stay, or reoperation rates due to abdominal complications. Therefore, it can be a valuable addition in DIEP flap breast reconstructions.

Preservation of the Implant in Nipple-Sparing Mastectomies: A Retrospective Cohort Study.

BACKGROUND: Mastectomies are an integral part of breast cancer treatment for many patients.1 Of those patients, a significant number have previously undergone breast augmentation before being diagnosed with breast cancer. Therefore, we developed the novel technique of performing nipple- and implant-sparing mastectomies (NISMs) for women with prior breast augmentations. This study will assess the plausibility of using NISMs versus nipple-sparing mastectomies (NSMs) in this subgroup of patients by comparing the complication rates. METHODS: Data were collected on age, tumor size, tumor grade, receptors, and the interval between mastectomy and implant exchange for both groups. Descriptive statistics were used to summarize patient characteristics. Independent samples t tests, χ2 tests, and Fisher exact tests were used to compare the NISM and NSM cohorts. Logistic regression was used to assess the association between complications and mastectomy type and was summarized as an odds ratio with a 95% confidence interval. RESULTS: Fifteen patients underwent an NISM and 35 patients underwent an NSM. The overall rate of complications was less in NISM cases than in NSM cases (20% vs 27%). However, this difference was not statistically significant (odds ratio, 0.54; 95% confidence interval, 0.18-1.64; P = 0.278). CONCLUSIONS: The overall complication rate was lower with NISMs compared with NSMs. Nipple- and implant-sparing mastectomy is a novel, viable, and safe option for patients with breast cancer and a history of submuscular breast augmentation.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. METHODS: A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. RESULTS: There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). CONCLUSIONS: The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Review of Procedures for Reconstruction of Soft Tissue Chest Wall Defects Following Advanced Breast Malignancies.

The purpose of this article is to review closure options for complex chest wounds in patients with locally advanced breast cancer. Experiences of the plastic and oncologic surgery teams at Moffitt Cancer Center were reviewed, and the literature researched for various surgical options of complex chest wound closure. Multiple treatment modalities exist for reconstruction of complex chest wall wounds with the external oblique and V-Y latissimus dorsi musculocutaneous advancement flaps serving as workhorses in reconstruction. Treatment of cancer has moved from simply a surgical solution to include other modalities such as hormonal therapy, chemotherapy, and radiation-the latter 2 having serious consequences for wound healing. A team approach and knowledge of available flap options are vital for closure of complex wounds in a timely manner. Appropriate planning can optimize the primary goal of the oncologic surgeon to remove the cancer and the plastic surgeon's objective to reconstruct the defect and achieve a closed, durable wound prior to chemotherapy and radiation. We present the experience at the Moffitt Cancer Center in reconstructing challenging chest defects and review the reconstructive ladder.

Improvement in Existing Chest Wall Irregularities During Breast Reconstruction.

Mastectomies for both cancer resection and risk reduction are becoming more common. Existing chest wall irregularities are found in these women presenting for breast reconstruction after mastectomy and can pose reconstructive challenges. Women who desired breast reconstruction after mastectomy were evaluated preoperatively for existing chest wall irregularities. Case reports were selected to highlight common irregularities and methods for improving cosmetic outcome concurrently with breast reconstruction procedures. Muscular anomalies, pectus excavatum, scoliosis, polythelia case reports are discussed. Relevant data from the literature are presented. Chest wall irregularities are occasionally encountered in women who request breast reconstruction. Correction of these deformities is possible and safe during breast reconstruction and can lead to improved cosmetic outcome and patient satisfaction.

Outcomes in Deep Inferior Epigastric Perforator Flap and Implant-Based Reconstruction: Does Age Really Matter?

Despite the growing elderly population, there is limited research specific to this demographic concerning breast reconstruction (BR). Lack of evidence-based BR recommendations in older populations may contribute to misconceptions and subsequent underutilization of BR, especially autologous BR. Patients who received either deep inferior epigastric perforator (DIEP) flap BR or tissue expander/implant (TE/I) BR by a single surgeon between July 2011 and July 2015 were surveyed postoperatively by using the psychometrically validated BREAST-Q questionnaire to determine patient satisfaction. Patients were categorized into younger and older cohorts based on median age (55 years) and further stratified based on the type of reconstruction. Of the 311 patients surveyed, 95 patients responded (31% response rate). Overall, younger patients (<55 years old, n = 42) compared with older patients (≥55 years old, n = 53) had significantly higher satisfaction with their outcome (mean difference [MD] 12.06; 95% confidence interval [CI]: 0.96-23.15; P = 0.034). In the TE/I group (n = 58), younger patients had significantly higher satisfaction with breasts (MD: 14.17; 95% CI: 2.58-25.75; P = .017) and outcome (MD: 18.25; 95% CI: 3.95-32.5; P = .010) with fewer complications (odds ratio [OR]: 3.29; 95% CI: 1.37-7.86; P = .010). In the DIEP flap group (n = 55), there was no significant difference inr any of the satisfaction outcomes between younger and older patients. Younger patients tend to be more satisfied and demonstrate fewer complications with implant-based BR. In contrast, both younger and older patients undergoing abdominally based autologous BR were equally satisfied with comparable outcomes.

Outcomes of 270 Consecutive Deep Inferior Epigastric Perforator Flaps for Breast Reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap has gradually become the superior choice for autologous breast reconstruction because it reduces donor site morbidity, abdominal wall complications, and postoperative recovery time when compared with other flap types. METHODS: The purposes of this study are to report on the experience and clinical outcomes of consecutive DIEP flap breast reconstructions performed by a single surgeon at a cancer center between April 2011 and May 2016 and to characterize the trends among these flaps. RESULTS: Two hundred seventy DIEP flaps from 202 consecutive patients were assessed. Patient ages ranged from 31 to 73 years, with a mean (SD) of 52.81 (9.89) years. Ischemia time ranged from 17 to 211 minutes (mean [SD], 51.51 [23.02] minutes), and procedure length (including mastectomy time) was between 224 and 950 minutes (mean [SD], 548.13 [154.77] minutes). Venous coupler size was between 2 and 4 mm (mean [SD], 2.69 [0.33] mm), and 1 to 3 perforating vessels were maintained per flap (mean [SD], 1.71 [0.68] perforators). Total reexploration rate was 3.3% (n = 9), and the total complete flap loss rate was 1.1% (n = 3). CONCLUSIONS: In our experience, the DIEP flap is a safe, consistent, and reliable option for breast reconstruction.

Flap-Mastopexy in Autologous Breast Reconstruction: Timing and Technique.

BACKGROUND: Techniques in breast reconstruction have significantly advanced the possibility to create more natural and aesthetically appealing breasts. Despite thorough preoperative planning and vigilant operative technique, symmetry remains a concern for select patients who have undergone autologous breast reconstruction. Although symmetry procedures of the contralateral breast have been well described in the literature, little has been published regarding secondary revision in the autologous reconstructed breast, leaving uncertainty as to the appropriate timing and technique for revision procedures that will not hinder the viability of the flap. In this article, we provide an effective, reproducible and safe method of mastopexy after autologous breast reconstruction. METHODS: A retrospective review of all patients undergoing autologous breast reconstruction by a single surgeon between 2007 and 2014 was performed. Patients who underwent mastopexy after autologous breast reconstruction were included. Patient characteristics, type of reconstruction, staging of procedures, secondary operations, and complications were recorded. RESULTS: Ten patients with asymmetric autologous breast reconstruction underwent flap mastopexy in 1 or both breasts. Indications for mastopexy included asymmetry resulting from immediate loss of autologous flaps, unilateral fat necrosis, scarring after mastectomy flap necrosis, excess ptosis, and volume asymmetries. No flap loss, fat necrosis, or nipple loss occurred after flap mastopexy. CONCLUSIONS: The autologous mastopexy technique is a useful option in secondary refinement procedures for breast reconstruction. It provides a reliable and predictable method to adjust the inframammary fold, increase projection, and address excess ptosis. It has a low complication rate and can be safely and reliably performed as early as 3 months after initial reconstruction.

Moffitt Cancer Center Experience of Tissue Expander Breast Reconstruction: Does Acellular Dermal Matrix Increase Return to the Operating Room?

BACKGROUND: Tissue expander and implant remains the most common technique for breast reconstruction. A controversial topic within this method is routine use of acellular dermal matrix (ADM). Acellular dermal matrices have increased risks of infection, seroma, hematoma, skin flap necrosis, and total complications. METHODS: After an institutional review board approval, a retrospective chart review was conducted of 756 tissue expander with implant cases from November 2010 to November 2016 at Moffitt Cancer Center with 2 breast reconstruction surgeons. Patients were grouped in 2 groups: tissue expander alone reconstruction (TE) and tissue expander with ADM (TE + ADM). Complications were defined by return visits to the operating room for irrigation and debridement as well as for subsequent tissue expander placement. RESULTS: There were 703 patients in the TE group and 53 in the TE + ADM group. Patients undergoing TE + ADM reconstruction were 3 times more likely to experience return to operating room compared with patients undergoing TE alone (7.5% vs 2.4%). Patients were significantly more likely to undergo 3 or more subsequent tissue expander placement procedures with TE + ADM (54.7%) compared with TE alone (4.8%) (P < 0.0001). CONCLUSIONS: Although ADM may be appropriate for specific patients, its use in tissue expander breast reconstruction should be judiciously selected, because there is an observed increase in complications needing return to the operating room.

Oncoplastic Surgery: Keeping It Simple With 5 Essential Volume Displacement Techniques for Breast Conservation in a Patient With Moderate- to Large-Sized Breasts.

Oncoplastic surgery is an evolving field in breast surgery combining the strengths of breast surgical oncology with plastic surgery. It provides the surgeon the ability to excise large areas of the breast in the oncologic resection without compromising, and possibly improving, its aesthetic appearance. The purpose of this review is to provide a guide that could help a breast surgeon excise breast cancer in most areas of the breast using 5 oncoplastic techniques. These techniques would be used depending primarily on the location of the cancer in the breast and also on the size of the tumor.

Pain and Anxiety Levels of Patients Undergoing Tissue Expansion After Mastectomies: A Case Series Study.

The tissue expansion process is done after mastectomies to increase the submuscular space in preparation for the placement of permanent breast implant. The process is often believed to be painful by patients who are often intimidated by the prospect of mechanically stretching out their skin and muscle. This study aims to quantify the pain experienced by patients and determine the different pain management techniques used. We used a case series approach, in which patients who were undergoing serial tissue expansion process were asked to rate their pain and anxiety on a scale from 1 to 10, using a questionnaire and the visual analog scale. Pain was rated during and after the expansion procedure, and patients were also surveyed to find the most commonly used and most effective pain management technique. Patients typically reported very little pain during and after the procedure, with an average of 0.4 to 2.5 pain experienced out of 10. The pain did not last, on average, longer than 1 day. Furthermore, the most widely used and most helpful pain medication was ibuprofen. During the tissue expansion procedure, the mean anxiety level was 0.64 (1.3). The findings show that tissue expansion process is a relatively low pain procedure and is not a contraindication for undergoing breast reconstruction. Ibuprofen, a mild treatment with few side effects, was efficacious in pain relief though most patients required no pain relief.

In the Age of Breast Augmentation, Breast Reconstruction Provides an Opportunity to Augment the Breast.

BACKGROUND: Augmentation mammoplasty remains the most common cosmetic surgery procedure performed. The objective of this article is to evaluate the impact of augmented volume of the reconstructed breast in patients that undergo nipple-sparing mastectomy and patients previously augmented who undergo mastectomy with tissue expander/implant-based reconstruction. METHODS: Patients undergoing skin-sparing mastectomy, nipple-sparing mastectomy, and mastectomy after previous augmentation followed by tissue expander/implant-based reconstruction between June 2011 and April 2015 by 2 surgeons at the same institution were included. Retrospective chart review of the patients identified using these criteria was performed to record patient characteristics, complications, breast volume, implant volume, and percentage change in volume at the time of reconstruction. Percentage change of breast volume was calculated using the formula (implant breast weight)/(breast weight) for skin-sparing and nipple-sparing mastectomy patients and (final breast implant weight - [breast weight + augmentation breast implant weight])/([breast weight + augmentation breast implant]) for patients undergoing mastectomy following previous augmentation. RESULTS: A total of 293 patients were included in the study with 63 patients who underwent nipple-sparing mastectomy, 166 patients who underwent skin-sparing mastectomy, and 64 patients who underwent previous augmentation with subsequent mastectomy. Mean percentage change in breast volume was 66% in the nipple-sparing mastectomy group, 15% for the right breast and 18% for the left breast in the skin-sparing mastectomy group, and 81% for the right breast and 72% for the left breast in the mastectomy following previous augmentation group. Complication rate for nipple-sparing mastectomy was 27%, mastectomy following previous augmentation was 20.3%, and skin-sparing mastectomy group was 18.7%. CONCLUSION: Patients who undergo nipple-sparing mastectomy or mastectomy following previous augmentation have the ability to achieve greater volume in their reconstructed breast via tissue expander/implant-based reconstruction.

Unilateral Versus Bilateral Breast Reconstruction: Is Less Really More?

OBJECTIVE: Over the recent years, there has been an increase in prophylactic mastectomies with an associated increase in bilateral breast reconstruction. We aimed to compare outcomes in terms of patient satisfaction with unilateral versus bilateral breast reconstruction after deep inferior epigastric perforator (DIEP) flap and implant-based reconstruction. METHODS: Patients who underwent breast reconstruction by a single surgeon between July 2011 and July 2015 were surveyed using the independently validated BREAST-Q questionnaire. Mean satisfaction scores between patients undergoing unilateral versus bilateral breast reconstruction were compared and stratified based on the type of reconstruction [eg, DIEP flap, tissue expander to implant (TE/I)]. Groups were further categorized by age (patients <55 years and ≥55 years of age) and body mass index (<24.9 and >24.9). Complications were recorded. RESULTS: Of the 308 patients included, 118 (38%) had unilateral reconstruction (42 TE/I and 76 DIEP) and 190 (62%) had bilateral reconstruction (124 TE/I and 66 DIEP). A total of 95 patient surveys were included (31% response rate). Overall, patients receiving unilateral reconstruction demonstrated increased satisfaction with outcome (P = 0.028), psychosocial well-being (P = 0.043), and sexual well-being (P = 0.002). Complication rates were similar between unilateral and bilateral reconstruction. No significant differences for satisfaction were found in the TE/I group (N = 58; unilateral, 10; bilateral, 48).In the DIEP group (N = 37; unilateral, 20; bilateral, 17), those receiving unilateral reconstruction had higher satisfaction with outcome (P = 0.013) and sexual well-being (P = 0.014).Additionally, younger patients (<55 years) were more likely to undergo bilateral reconstruction (P = 0.018). Body mass index did not have a significant association with unilateral or bilateral reconstruction. CONCLUSIONS: Patients undergoing DIEP flap reconstruction showed higher satisfaction with unilateral reconstruction, whereas patients receiving TE/I reconstruction, either unilateral or bilateral, were equally satisified. Additionally, younger women were more likely to undergo bilateral reconstruction, which is consistent with current data trends. When considering surgical options, unilateral DIEP flap reconstruction may provide improved outcomes in terms of patient satisfaction when compared with bilateral reconstruction in select patients.

Single Institution Review of Patients With Prior Breast Augmentation Undergoing Breast Conservation Therapy for Breast Cancer.

BACKGROUND: Increasing number of patients with preexisting breast implants desire breast conservation therapy for breast cancer. There is paucity of comparative data on tumor margins and re-excisions in these patients. High re-excision rates up to 25% have been reported in breast conservation therapy patients; efforts to obtain cosmesis and avoid implant rupture might increase this further. We analyzed tumor margins, re-excision rates, and recurrence in previously augmented versus non-augmented patients undergoing lumpectomy for breast cancer. We preserved preexisting implants if feasible with oncologic clearance and cosmesis. METHODS: Institutional review board-approved retrospective analysis was performed on patients undergoing lumpectomy with history of prior breast augmentation (N = 52) and consecutively selected non-augmented patients (N = 51). Based on tumor distance to inked margin, we grouped margins as negative (≥2 mm), close (<2 mm), and positive. Patients were followed up clinically and with imaging in the outpatient clinic, and recurrences were documented. RESULTS: Patients in the non-augmented group were significantly more likely to have larger tumors (T2 and above; P = 0.05) compared with the augmented group. Although more patients in the augmented group had positive margins, this was not statistically significant (6 vs 3, P = 0.86). No difference was noted between re-excision rates among the augmented versus non-augmented groups (21.1% vs 19.6%, respectively; odds ratio, 0.91; 95% confidence interval, 0.35-2.37; P = 0.85); these remained unchanged even when adjusting for tumor stage (P = .75) and margins (P = 0.73). Although more patients in the augmented group recurred (4 vs 0), this was not statistically significant (P = 0.1). CONCLUSIONS: Our results indicate that, from the oncological standpoint, patients with prior augmentation can undergo lumpectomy with equivalent tumor margins and re-excision rates. To the best of our knowledge, this is the first reported comparative study between these 2 groups.

Complications and Recurrence in Implant-Sparing Oncologic Breast Surgery.

BACKGROUND: Patients with a history of prior breast augmentation and newly diagnosed breast cancer represent a rapidly expanding and unique subset of patients. Prior studies have described changes in breast parenchyma and characteristic body habitus of previously augmented patients, as well as increased rates of capsular contracture associated with breast conservation therapy. In our current study, we aimed to study the risk factors contributing to morbidity and whether recurrence rates are higher in patients with prior breast augmentation undergoing lumpectomy or mastectomy for breast cancer and identify differences in complications between these 2 groups. METHODS: Retrospective analysis approved by institutional review board was performed on patients with prior breast augmentation undergoing lumpectomy (N = 52) and mastectomy (N = 64) for breast cancer. RESULTS: Patients with prior breast augmentation undergoing mastectomy had a higher rate of complications compared with those undergoing lumpectomy (20.3% vs 5.9% respectively, P = 0.031), after adjusting for patient-specific factors including body mass index [odds ratio (OR), 0.242; 95% confidence interval (CI), 0.063-0.922; P = 0.0376], tumor stage (OR, 0.257; 95% CI, 0.064-1.036; P = 0.0562), smoking status (OR, 0.244; 95% CI, 0.065-0.918; P = 0.0370), and chemotherapy (OR, 0.242; 95% CI, 0.064-0.914; P = 0.0364). Four patients (7.7%) developed late complications in the lumpectomy group with 2 developing capsular contractures, 1 had fat necrosis and 1 needed complex reconstruction because of flattening of the nipple-areolar complex. There was no difference in recurrence or tumor margins between lumpectomy and mastectomy groups. CONCLUSIONS: Patients with prior breast augmentation undergoing mastectomy have higher complication rates compared with lumpectomy even after adjusting for tumor stage. There appears to be no increased oncologic risk associated with either procedure given our current follow-up. Understanding these operative risks may help in patients' decision-making process with regards to type of oncologic surgery.

Duoderm®-Bra for Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) with tissue expander reconstruction is a widely used technique that can produce aesthetically pleasing reconstruction results after mastectomy. Nipple position and healthy mastectomy flaps with good vascularity are important determinants of an adequate aesthetic final result. An initial high fill volume of the expander can produce a more natural breast mound appearance postoperatively. However, this can often lead to ischemia with loss of the nipple-areolar complex (NAC). Conversely, low intraoperative fill rates are conducive to enhanced tissue circulation and viability. But this may lead to poor skin envelope draping and nipple placement lower than desired. We have developed a new technique called "Duoderm®-bra" that brings together both mastectomy skin tissue health and aesthetic success with optimal nipple positioning. We hypothesized that with Duoderm®-bra, the NAC can be stabilized in the desired high position and ptosis can be reduced. We also hypothesized that by eliminating the need for acellular dermal matrix and intraoperative fill, "Duoderm®-bra" would decrease the rate of complications. The objective of this study was to evaluate the effects of using novel "Duoderm®-bra" technique in NSM. METHODS: After an institutional review board approval, a retrospective chart review of 35 consecutive patients was done with 65 breasts undergoing NSM and tissue expander reconstruction by the same plastic surgeon. Patients in whom "Duoderm®-bra" was used were compared with patients without the "Duoderm®-bra." Patients with acellular dermal matrix were excluded. Age, ptosis grade, preoperative nipple to IMF ratio (R/L), tumor characteristics, mastectomy specimen weight (R/L), time from mastectomy to first fill, time from mastectomy to final fill, final fill volume (R/L), NAC and skin necrosis, and other complications requiring surgery were recorded. Postoperative photographs for NAC positioning (side view most projected point versus at a lower point) were assessed using a scoring system. Two groups were then compared. RESULTS: Complications were higher in the non-Duoderm® group compared with Duoderm®-bra (odds ratio, 4.5; 95% confidence interval [CI], 1.35-15.04; P = 0.021). Optimum nipple positioning was significantly higher with Duoderm®-bra compared with no Duoderm®-bra (odds ratio, 50.0; 95% CI, 10.9-230.1; P < 0.0001). There was no difference in timing from mastectomy to completion of expansion in the Duoderm® group compared with no Duoderm®-bra group (mean difference, -2.35; 95% CI, -10.37 to 5.68). CONCLUSIONS: Use of "Duoderm®-bra" without intraoperative tissue expansion in NSM is a new technique. This technique improves nipple position with less ptosis and greater elevation, decreases flap and NAC necrosis complications, and does not increase total reconstructive period in NSM patients.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

BACKGROUND: Women who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. METHODS: Institutional review board-approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. RESULTS: Fifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). CONCLUSIONS: Implant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.

Vertical Mastectomy Incision in Implant Breast Reconstruction After Skin Sparing Mastectomy: Advantages and Outcomes.

BACKGROUND: The type of since skin-sparing mastectomy (SSM) incision directly impacts the final aesthetic and functional results of reconstruction. Different incisions are used for SSM depending on tumor location, previous biopsy scars, breast weight, and ptosis degree. A vertical scar is less visible to the patient, reminiscent of a mastopexy, and patients may not have the stigma of mastectomy. OBJECTIVE: This study investigates complication rates, patient demographics, patient reported outcomes, and plastic surgeon evaluations to compare vertical incision mastectomy to other incisions. METHODS: After institutional review board approval, a retrospective chart review was performed. A total population of 167 patients that underwent mastectomy with tissue expander reconstruction was separated into vertical incision and nonvertical incision mastectomy groups consisting of 38 and 129 patients, respectively. Patient demographics, complications, tumor margins, staging, breast weight, and breast implant volume were compared. BREASTQ Survey analysis was conducted using patient reported outcomes from the patient's perspective. Aesthetic evaluations of postoperative photos were systematically scored by plastic surgeons to obtain data from the plastic surgeon's perspective. RESULTS: Vertical incision orientation did not increase surgical complication rates or mastectomy skin necrosis (P = 0.142). Vertical incisions did not interfere with obtaining adequate tumor margins (P = 0.907). Vertical incisions did not have a significantly different breast weight or implant volume. There was no statistical difference for patient satisfaction or plastic surgeon aesthetic evaluation. CONCLUSIONS: The use of vertical incision does not increase complication rates; does not interfere with tumor margins; and can be applied to all age, BMI, breast weight, and breast implant volume groups.