Implications of the COVID-19 Pandemic on Immediate Breast Reconstruction Access.

AIMS: As a result of COVID-19, there have been restrictions on surgical interventions across Canada. Immediate breast reconstruction (IBR), while an essential component of cancer care, is classified as elective surgery and therefore has been restricted in access over the course of the pandemic. The purpose of this study was to compare wait times for breast cancer patients undergoing surgical intervention for IBR before and since the COVID-19 pandemic. METHODS: This was a retrospective cross-sectional study of consecutive patients who underwent IBR between July 2018 and October 2021 by 5 plastic surgeons at a single Canadian health center. Wait times to consultation and surgical intervention between pre- and post-COVID cohorts were analyzed. RESULTS: A total of 161 patients met inclusion criteria. For ablative surgery, there was no difference in wait times to surgical oncology consultation (14.0 ± 12.3 vs 14.0 ± 11.0 days, P = 0.991) and surgical intervention with IBR (41.0 ± 49.8 vs 35.0 ± 58.0 days, P = 0.621) between the pre- and post-COVID cohorts. For breast reconstruction, while time to consultation with plastic surgery (12.5 ± 14.8 vs 11.0 ± 12.8 days, P = 0.775) remained unchanged, usage of autologous techniques was reduced [n = 13 (16%) vs n = 2 (2%), P = 0.006], and time to second-stage alloplastic reconstruction increased (230 ± 102 vs 325 ± 224 days, P = 0.044) post-COVID. CONCLUSIONS: Swift adoption of evidence driven protocols has resulted in comparable wait times for breast cancer ablative procedures. However, utilization of autologous techniques and wait times to second-stage reconstructions have increased.

Management of patients requiring reconstructive breast surgery during the COVID-19 pandemic: recommendations from the BC Regional Breast Reconstruction Network.

Summary: The COVID-19 pandemic has caused unprecedented challenges in health care, threatening access and delivery of medical services across all sectors. Patients with breast cancer desiring breast reconstruction require timely interdisciplinary care; resource limitations threaten access to this elective reconstructive element of cancer care. An expert panel was convened to identify challenges, recommend preliminary solutions, and identify important future directions in anticipation of prolonged restrictions. This paper presents consensus recommendations for care of breast cancer reconstruction patients during the pandemic based on expert opinion from the BC Breast Reconstruction Network.

Recurrent Breast Cerebrospinal Fluid Pseudocyst: A Complication of Ventriculoperitoneal Shunt Placement.

Ventriculoperitoneal (VP) shunt complications involving the breast are rare, with the majority involving the formation of a cerebrospinal fluid pseudocyst. We present the case of a 22-year-old woman with recurrent cerebrospinal fluid pseudocyst secondary to fracture of a VP shunt at the time of breast surgery for breast asymmetry. We review the literature on this topic and present our case that highlights the need of the breast surgeon to take into account the position of VP shunts placed at birth. Shunts placed on the chest wall may result in breast asymmetry requiring surgery in the adolescent. Shunts in place since birth may be at greater risk of fracture during breast implant placement due to manipulation of a calcified and fragile shunt leading to formation of a cerebrospinal fluid pseudocyst.

Autologous Breast Reconstruction in Women Older Than 65 Years Versus Women Younger Than 65 Years: A Multi-Center Analysis.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson χ² and analysis of variance tests were used. Given the number of analyses, a more conservative α of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

Predictors of Mastectomy Flap Necrosis in Patients Undergoing Immediate Breast Reconstruction: A Review of 718 Patients.

BACKGROUND: Mastectomy flap necrosis (MFN) after mastectomy and immediate breast reconstruction can compromise postsurgical recovery, lead to additional surgeries, and compromise aesthetic outcome. The objective of this study was to determine if there is a difference in the rate of MFN in patients undergoing immediate alloplastic versus immediate autologous breast reconstruction. The secondary objective was to identify additional patient and surgical factors that may influence the rate of MFN. METHODS: A retrospective chart review of patients who underwent immediate breast reconstruction between 2003 and 2011 in the University of British Columbia Breast Program was performed. Demographic, oncologic, reconstructive, and surgical data were compiled. RESULTS: Approximately 404 alloplastic and 314 autologous patients were reviewed. The overall rate of MFN was 12.9%. There was a trend toward a higher MFN rate in the autologous patient group (15.2% vs 11.6%, P = 0.095). After controlling for age, body mass index (BMI), smoking status, preoperative breast radiation, surgery duration, cancer side, mastectomy type, and postoperative chemotherapy, no association was found between reconstruction type and MFN. BMI greater than 30, smoking status, and preoperative radiation were independent predictors of MFN. Surgical factors including longer duration of surgery and Wise pattern mastectomy incision were also found to be associated with increased odds of MFN. CONCLUSION: We found no difference in the rate of MFN when comparing immediate alloplastic and autologous reconstruction methods. A number of patient and surgical factors were found to be predictors of MFN. The results of this large, retrospective study will help surgeons to tailor their reconstruction based on a patient's risk factors to minimize the incidence of MFN.

Implant breast reconstruction and radiation: a multicenter analysis of long-term health-related quality of life and satisfaction.

BACKGROUND: Indications for radiotherapy in breast cancer treatment are expanding. Long-term satisfaction and health-related quality of life (HR-QOL), important outcomes after alloplastic breast reconstruction and radiation, have not been measured in irradiated patients by using a condition-specific, validated patient-reported outcomes instrument. The aim was to evaluate patient satisfaction and HR-QOL in patients with implant breast reconstruction and radiotherapy. METHODS: A multicenter cross-sectional survey of patients who underwent implant-based breast reconstruction from three centers in the United States and Canada, with and without radiation, was performed. Satisfaction with breasts, satisfaction with outcome, psychosocial well-being, sexual well-being, and physical well-being outcomes were evaluated using the BREAST-Q(©) (Reconstruction Module). Multivariable analysis was performed to evaluate the effect of radiotherapy on patient satisfaction with breasts with adjustment by patient and treatment characteristics. RESULTS: The response rate was 71 %, with 633 completed questionnaires returned. Mean follow-up was 3.3 years for irradiated patients (n = 219) and 3.7 years for nonirradiated patients (n = 414). Patients with radiation had significantly lower satisfaction with breasts (58.3 vs. 64.0; p < 0.01), satisfaction with outcome (66.8 vs. 71.4; p < 0.01), psychosocial well-being (66.7 vs. 70.9; p < 0.01), sexual well-being (47.0 vs. 52.3; p < 0.01), and physical well-being (71.8 vs. 75.1; p < 0.01) compared with nonirradiated patients. Multivariable analysis confirmed the negative effect of radiotherapy on satisfaction with breasts (ß = -2.6; p = 0.03) when adjusted for patient and treatment factors. CONCLUSIONS: Radiotherapy has a negative effect on HR-QOL and satisfaction with breasts in patients with implant reconstruction compared with nonirradiated patients. The information provided here can inform decision-making and help set appropriate expectations for patients undergoing implant breast reconstruction and radiation.

Conversion from Alloplastic to Autologous Breast Reconstruction: What Are the Inciting Factors?

Introduction: Failure of alloplastic breast reconstruction is an uncommon occurrence that may result in abandonment of reconstructive efforts or salvage with conversion to autologous reconstruction. The purpose of this study was to identify factors that predict failure of alloplastic breast reconstruction and conversion to autologous reconstruction. Methods: A retrospective chart review was conducted of patients who underwent mastectomy and immediate alloplastic breast reconstruction between 2008 and 2019. Inclusion criteria included patients 18 years or older who underwent initial alloplastic reconstruction with a minimum of 3-year follow-up. Data collected included age, body mass index, cancer type, surgical characteristics, neo/adjuvant treatment details, and complications. Results were analyzed using Fischer's exact test, t-test, and multivariate logistic regression. Results: A total of 234 patients met inclusion criteria. Of those, 23 (9.8%) required conversion from alloplastic to autologous reconstruction. Converted patients had a mean age of 50.1 ± 8.5. The time from initial alloplastic reconstruction to conversion was 30.7 months. The most common reasons for conversion included soft tissue deficiency (48%), infection (30%), and capsular contracture (22%). Patients were converted to deep inferior epigastric perforator flap (DIEP; 52%), latissimus dorsi flap with implant (26%), and DIEP with implant (22%). Multivariate logistic regression modeling identified radiation (OR 8.4 [CI = 1.7-40.1]) and periprosthetic infection (OR 14.6 [CI = 3.4-63.8]) as predictors for conversion. Conclusions: Among patients undergoing mastectomy with immediate alloplastic breast reconstruction, those treated with radiation have 8.4 greater odds of conversion and those with a periprosthetic infection have 14.6 greater odds for conversion to an autologous reconstruction.

Introduction : L'échec d'une reconstruction mammaire alloplastique est un événement peu fréquent qui peut aboutir à un abandon des efforts de reconstruction ou à une solution de secours avec une conversion en reconstruction autologue. L'objectif de cette étude était d'identifier les facteurs prédisant l'échec de la reconstruction mammaire alloplastique et sa conversion en reconstruction autologue. Méthodes : Une étude rétrospective a été menée sur les dossiers de patientes ayant subi une mastectomie suivie d'une reconstruction mammaire alloplastique immédiate entre 2008 et 2019. Les critères d'inclusion étaient notamment des patientes âgées d'au moins 18 ans ayant subi une reconstruction alloplastique initiale avec un suivi minimum de 3 ans. La collecte de données a inclus : l'âge, l'indice de masse corporelle (IMC), le type de cancer, les caractéristiques chirurgicales, les détails sur le traitement adjuvant/néoadjuvant et les complications. Les résultats ont été analysés à l'aide du test t exact de Fischer, un test t et une analyse de régression logistique multifactorielle. Résultats : Un total de 234 patientes a satisfait les critères d'inclusion. Parmi ces patientes, 23 (9,8%) ont nécessité la conversion de la reconstruction alloplastique en reconstruction autologue. Les patientes « converties ¼ avaient un âge moyen de 50,1 ± 8,5 ans. Le délai séparant la reconstruction alloplastique initiale et la conversion était de 30,7 mois. Les motifs les plus fréquents de conversion étaient une déficience des tissus mous (48%), une infection (30%) et la formation d'une coque (22%). Les techniques de conversion utilisées étaient la technique dite DIEP ou AEIP (artère épigastrique inférieure profonde, 52%), un lambeau du grand dorsal avec implant (26%), et la technique DIEP avec implant (22%). Une modélisation d'analyse de régression logistique multifactorielle a identifié les facteurs prédictifs de conversion suivants : irradiation (rapport de cotes = 8,4 [IC = 1,7-40,1]) et l'infection périprothétique (RC = 14,6 [IC = 3,4 à 63,8]). Conclusions : Parmi les patientes subissant une mastectomie avec reconstruction mammaire alloplastique immédiate, celles qui ont reçu une radiothérapie avaient un risque de conversion 8,4 fois plus grand et les patientes ayant une infection périprothétique avaient un risque 14,6 fois plus grand de conversion en reconstruction autologue.

Prevalence and Severity of Chronic Pain in Patients Receiving Mastectomy with Alloplastic Immediate Breast Reconstruction: A Survey Study.

Introduction: Breast cancer is the most frequently diagnosed cancer worldwide. For those undergoing mastectomy, the choice of alloplastic immediate breast reconstruction (IBR) is increasingly favored. Post-operative chronic pain is an important consideration in this decision, but there is a paucity of data for those undergoing alloplastic IBR. We sought to examine the prevalence, severity, and risk factors for the development of chronic pain in this cohort using validated patient-reported outcome measures. Methods: A cross-sectional survey study was conducted among patients receiving mastectomy with alloplastic IBR. Participants completed 3 surveys querying chronic pain, specifically the Breast Cancer Pain Questionnaire (BCPQ), Brief Pain Inventory (BPI), and BREAST-Q. Participant medical records were reviewed for demographic and surgical variables. Results: A total of 118 patients participated in the study-a response rate of 33.6%. Chronic pain prevalence was high (52.5%), and only 29.0% of these patients had consulted a physician regarding their pain. Among those reporting chronic pain (n = 62), the median severity of pain was 3.1 on an 11-point scale. Chronic pain was associated with radiation (p = .018), bilateral reconstruction (p = .05), worse emotional health (p = .0003), less self (p = .022), and sexual confidence (p = .044). Inter-tool reliability was high, with no significant difference in responses between the 3 surveys. Conclusion: In this cohort, chronic pain is supported as a significant concern among patients who have undergone mastectomy with alloplastic IBR. Given the burden of chronic pain, there is an opportunity to intervene with preventative measures and support for its management.

Introduction: Le cancer du sein est le cancer le plus souvent diagnostiqué dans le monde. L'option de reconstruction mammaire immédiate (RMI) alloplastique est de plus en plus souvent choisie par les patientes subissant une mastectomie. La douleur chronique postopératoire est un important facteur à prendre en compte dans cette décision, mais nous ne disposons que peu de données pour les patientes ayant une RMI alloplastique. Nous avons cherché à étudier la prévalence, la sévérité et les facteurs de risque de survenue d'une douleur chronique dans cette population de patients au moyen de mesures validées de déclaration des résultats. Méthodes: Une enquête transversale a été réalisée parmi les patientes ayant bénéficié d'une RMI alloplastique. Les participants ont répondu à trois enquêtes portant sur la douleur chronique (plus spécifiquement le questionnaire sur la douleur dans le cancer du sein [BCPQ], le Questionnaire court sur la douleur [BPI ou Brief Pain Inventory] et le BREAST-Q). Les dossiers médicaux des participantes ont été examinés à la recherche des variables démographiques et chirurgicales. Résultats: Un total de 118 patientes a participé à l'étude, soit un taux de réponse de 33.6%. La prévalence de la douleur chronique était élevée (52.5%) et seulement 29.0% de ces patientes avaient consulté un médecin à propos de cette douleur. Parmi les participantes signalant une douleur chronique (n = 62), la sévérité médiane de la douleur était de 3,1 sur une échelle de 11 points. La douleur chronique a été associée à la radiothérapie (p = .018), à une reconstruction bilatérale (p = .05), à une aggravation de la santé émotionnelle (p = .0003), à une moindre confiance en soi (p = .022) et sur le plan de la sexualité (p = .044), La fiabilité inter-outils a été élevée, sans différence significative entre réponses dans les trois enquêtes. Conclusion: Il est confirmé que, dans cette cohorte, la douleur chronique est une préoccupation importante chez les patientes ayant subi une mastectomie avec RMI alloplastique. Considérant le fardeau que représente la douleur chronique, il y a une opportunité d'intervention en utilisant des mesures préventives et en apportant un soutien pour sa gestion.

The influence of dispositional optimism on decision regret to undergo major breast reconstructive surgery.

BACKGROUND & OBJECTIVES: It is not known if optimism influences regret following major reconstructive breast surgery. We examined the relationship between dispositional optimism, major complications and decision regret in patients undergoing microsurgical breast reconstruction. METHODS: A consecutive series of 290 patients were surveyed. Independent variables were: (1) dispositional optimism and (2) major complications. The primary outcome was Decision Regret. A multivariate regression analysis determined the relationship between the independent variables, confounders and decision regret. RESULTS: Of the 181 respondents, 63% reported no regret after breast reconstruction, 26% had mild regret, and 11% moderate to severe regret. Major complications did not have a significant effect on decision regret, and the impact of dispositional optimism was not significant in Caucasian women. There was a significant effect in non-Caucasian women with less optimism who had significantly higher levels of mild regret 1.36 (CI 1.02-1.97) and moderate to severe regret 1.64 (CI 1.0-93.87). CONCLUSIONS: This is the first paper to identify a subgroup of non-Caucasian patients with low dispositional optimism who may be at risk for developing regret after microsurgical breast reconstruction. Possible strategies to ameliorate regret may involve addressing cultural and language barriers, setting realistic expectations, and providing more support during the pre-operative decision-making phase.

Determinants of Success in Single- and Multi-Digit Replant.

Purpose: Understanding the variables that influence success in digital replant surgery is essential to guide clinical decision-making and to counsel patients. The purpose of this study was to determine the replant success rate and identify predictors of success at our tertiary care centre. Methods: This was a single centre, retrospective cohort study of consecutive patients who underwent digital replantation from January 2000 to September 2018. Adult patients with flexor zone I to III amputations were included. Patient demographics, comorbidities, injury pattern, operative data, and post-operative care were reviewed. The primary outcome was survival of the replanted digit at discharge. Results: A total of 146 patients met inclusion criteria. Of these, 100 had single-digit replants and 46 underwent multi-digit replants for a total of 220 digits. The success rate was 71%. Predictors of success included sharp mechanism of injury (P < .01), incomplete amputation (P < .01), amputation proximal to zone I flexor level (P = .02), post-operative acetylsalicylic acid use (P < .01), absence of leech use (P = .05), and absence of operative re-exploration (P < .01). Daytime replants had similar outcome compared to nighttime replants despite having increased ischemia time (7.9 ± 3.9 hours vs 6.8 ± 2.6 hours, P = .02). However, daytime operative time (7.8 ± 3.7 hours) was significantly shorter than nighttime replant time (9.6 ± 5.9 hours, P = .01). Conclusion: Sharp amputation, intact venous drainage, proximal amputation, and acetylsalicylic acid use were associated with replant survival and are factors to consider when managing patients for digital replantation. Leech therapy and operative re-exploration were associated with poor outcome. Nighttime replants required significantly longer operative time than daytime replants despite similar survival outcome.

Objectif: Il est essentiel de comprendre les variables qui influent sur la réussite de la réimplantation digitale par voie chirurgicale pour orienter les décisions et conseiller les patients. La présente étude visait à déterminer le taux de réussite des réimplantations et à déterminer les prédicteurs de réussite au centre de soins tertiaires des chercheurs. Méthodologie: Cette étude de cohorte monocentrique et rétrospective portait sur des patients consécutifs qui avaient subi une réimplantation chirurgicale entre janvier 2000 et septembre 2018. Les patients adultes ayant subi des amputations des zones I à III des fléchisseurs ont été retenus. Les chercheurs ont évalué les caractéristiques démographiques des patients, leurs maladies associées, leur type de blessures, les données opératoires et leurs soins postopératoires. La survie du doigt réimplanté au congé était le résultat primaire. Résultats: Au total, 146 patients ont respecté les critères d'inclusion. De ce nombre, 100 avaient fait réimplanter un seul doigt et 46, plusieurs doigts, pour un total de 220 doigts. Le taux de réussite s'élevait à 71%. Les prédicteurs de réussite incluaient un mécanisme franc de blessure (p<0,01), une amputation incomplète (p<0,01), une amputation proximale au fléchisseur de la zone I (p=0,02), la prise d'acide acétylsalicylique après l'opération (p<0,01), la non-utilisation de sangsues (p=0,05) et l'absence de réexploration opératoire (p<0,01). Les réimplantations effectuées le jour donnaient des résultats semblables à celles qui étaient effectuées la nuit, malgré une durée d'ischémie plus longue (7,9±3,9 h par rapport à 6,8±2,6 h, p=0,02). Cependant, les opérations exécutées le jour (7,8±3,7 h) était beaucoup plus courtes que celles effectuées la nuit (9,6±5,9 h, p=0,01). Conclusion: Une amputation franche, un drainage veineux intact, une amputation proximale et la prise d'acide acétylsalicylique étaient liés à la survie de la réimplantation et représentent des facteurs à considérer dans la prise en charge des patients qui doivent subir une réimplantation digitale. La thérapie par les sangsues et la réexploration opératoire étaient associées à un mauvais pronostic clinique. Les réimplantations opératoires effectuées la nuit étaient beaucoup plus longues que celles effectuées le jour, malgré un taux de survie semblable.

Skin-sparing mastectomy and immediate autologous breast reconstruction in locally advanced breast cancer patients: a UBC perspective.

PURPOSE: To describe the clinical outcomes of patients with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy and preoperative radiotherapy, followed by skin-sparing mastectomy (SSM) and immediate autologous breast reconstruction (IABR). METHODS: A retrospective review of 30 LABC patients who underwent SSM and IABR between 1997 to 2007 was performed. Data were drawn from patient records and the University of British Columbia (UBC) Breast Reconstruction and British Columbia Cancer Agency databases. RESULTS: All 30 patients received neoadjuvant chemotherapy, preoperative radiotherapy, SSM, and IABR. Fifteen patients (50%) had stage IIIA disease, 13 (43%) stage IIIB, and 2 (6.7%) stage IIIC. Reconstruction types included the pedicled transverse rectus myocutaneous flap (n = 24), the latissimus dorsi flap (n = 5), and a combination of transverse rectus myocutaneous and latissimus dorsi flap (n = 1). The median follow-up was 3.51 years (range 1-9.4 years). Local complications included mastectomy flap necrosis (n = 3), partial flap necrosis (n = 1), fat necrosis (n = 1), seroma (n = 3), infection (n = 2), and flap fibrosis (n = 1). The incidence of donor site complications was 20%. Overall 5-year actuarial locoregional relapse-free, distant relapse-free, and disease-specific survival rates were 80, 65, and 68%, respectively. Excellent or good physician-rated aesthetic results were achieved in 66% of patients. CONCLUSIONS: The UBC protocol avoids irradiation of the autologous breast reconstruction. Outcomes compare with findings from similar studies with respect to local recurrence, distant relapse, overall survival, and surgical complication rates. Neoadjuvant chemotherapy and preoperative radiotherapy in LABC patients desiring autologous breast reconstruction can be considered a safe option.

Citation Analysis in Breast Reconstruction Publications Between 2000 and 2010.

Introduction and Purpose: Breast reconstruction is an active area of plastic surgery research. Citation analysis allows for quantitative analysis of publications, with more citations presumed to indicate greater influence. We performed citation analysis to evaluate the most cited papers on breast reconstruction between 2000 to 2010 to identify contemporary research trends. Methods: The SCI-EXPANDED database was used to identify the 50 most cited papers. Data points included authorship, publication year, publication journal, study design, level of evidence, number of surgeons/institutions, center of surgery, primary outcome assessed, implant/flap/acellular dermal matrix/fat graft, acellular dermal matrix brand and use with implants/flaps, fat graft use with implants/flaps, unilateral/bilateral, one-/two-stage, immediate/delayed, number of patients/procedures, complications. Descriptive analysis of trends was performed based on results. Results: 20% of papers were published in 2006, 16% in 2007 and 12% in both 2004/2009. 66% were published in Plastic and Reconstructive Surgery. The majority were retrospective or case series, and of Level III or IV evidence. The one Level I study was a prospective multicenter trial. 21 and 7 papers discussed procedures by single/multiple surgeons, respectively. Results from single/multiple centers were discussed in 18 and 6 papers, respectively. 30 papers discussed implant-based reconstruction, 22 papers flap-based (19 microsurgical), 15 papers acellular dermal matrix, and five papers fat grafting. The primary focus in the majority was complications or outcomes. Conclusion: Our analysis demonstrates continually evolving techniques in breast reconstruction. However, there is notable lack of high quality evidence to guide surgical decision-making in the face of increasing surgical options.

Introduction et objectif: La reconstruction mammaire est un secteur actif de la recherche en chirurgie plastique. L'analyse de citations permet de procéder à une analyse quantitative des publications, un plus grand nombre de citations étant réputé indiquer une plus grande influence. Les chercheurs ont effectué une analyse de citations pour évaluer les articles les plus cités sur la reconstruction mammaire entre 2000 et 2010 et établir les tendances contemporaines de la recherche. Méthodologie: Les chercheurs ont utilisé la base de données SCI-EXPANDED pour extraire les 50 articles les plus cités. Les éléments de données incluaient les auteurs; l'année de publication; la revue; la méthodologie; la qualité des preuves; le nombre de chirurgiens et d'établissements, le centre chirurgical, l'évaluation des résultats primaires; l'implant, le lambeau, la matrice dermique acellulaire, la greffe de graisse; le type de matrice dermique acellulaire et son utilisation avec les implants et les lambeaux; l'utilisation de greffe de graisse avec les implants et les lambeaux; les reconstructions unilatérales ou bilatérales, en une ou deux phases, immédiates ou tardives; le nombre de patientes et d'interventions et les complications. Les chercheurs ont procédé à une analyse descriptive des tendances en fonction des résultats. Résultats: L'analyse a démontré que 20 % des articles ont été publiés en 2006, 16 % en 2007 et 12 % à la fois en 2004 et 2009. De plus, 66 % ont paru dans la revue Plastic and Reconstructive Surgery. La plupart étaient des études rétrospectives ou des séries de cas et contenaient des données probantes de niveau III ou IV. La seule étude de niveau I était un essai multicentrique prospectif. Par ailleurs, 21 articles ont traité d'interventions réalisées par un seul chirurgien, et sept, par de multiples chirurgiens. Les résultats monocentriques ont été abordés dans 18 articles, et les résultats multicentriques, dans six articles. Enfin, 30 articles portaient sur les reconstructions par implant, 22, sur les reconstructions par lambeau (dont 19 microchirurgies), 15, sur la matrice dermique acellulaire et cinq, sur les greffes de graisse. Les complications ou les résultats cliniques étaient l'objectif principal de la majorité des études. Conclusion: L'analyse a démontré que les techniques de reconstruction mammaire sont en constante évolution. Cependant, les données de qualité font défaut pour orienter les décisions chirurgicales à la lumière des possibilités chirurgicales croissantes.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting?

Breast cancer susceptibility gene (BRCA) mutation carriers have an increased risk of breast cancer. Mitigation of this risk can be achieved via surveillance or prophylactic mastectomy with or without breast reconstruction. Those that choose surgery expect to reduce their chance of developing cancer. The purpose of this study was to determine the incidence of patients developing breast cancer prior to surgery and to identify modifiable contributing factors within the patient journey. This is a historical cohort study of all BRCA mutation carriers identified through the British Columbia Cancer Hereditary Cancer Program between 2000 and 2012. Patients were divided into two groups: surveillance (S) and prophylactic mastectomy with immediate breast reconstruction (PM/IBR). The incidence of cancer, time to PM/IBR and patient journeys were analyzed. A total of 333 women were identified. The time to surgery from mutation disclosure was a median of 31 (5.3, 75.7) months. During this period, 6% of patients developed breast cancer compared with a 14% incidence of breast cancer in patients choosing surveillance. The majority of time to surgery was attributed to the period between mutation disclosure and the decision to proceed with surgery. Strategies to facilitate decision-making as well as wait list prioritization and dedicated operative time should be targeted to this population to decrease the number of women developing an interval cancer prior to surgery.

The surgical management of granulomatous mastitis.

Granulomatous mastitis is an inflammatory breast condition of unknown etiology. Management remains controversial and treatment algorithms are lacking from the literature. Few resources exist that discuss breast reconstruction following extirpation. This descriptive case series reviews the clinicopathologic features of granulomatous mastitis.We describe the surgical management undertaken at our institution including General and Plastic Surgery procedures. Eleven clinical charts and histologic slides of biopsy specimens were reviewed in our health region between 1992 and 2007. Demographic data, clinical presentation, and radiologic findings were tabulated. Treatment consisted of empirical antibiotics and surgical excision. Procedures performed included incision and drainage (n = 8), excisional biopsy (n = 15), partial mastectomy (n = 5), partial mastectomy with reduction mammaplasty (n = 2), and mastectomy with TRAM flap reconstruction (n = 1).Treatment was successful in all but one case. Multiple surgeries for recurrent lesions were often required to achieve final remission. Following extirpation, we recommend delayed breast reconstruction to monitor for recurrence.

Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature.

PURPOSE: The primary objective of this systematic review was to identify and analyze the outcomes measures that have been used to evaluate postoperative results following surgery for cubital tunnel syndrome. The secondary objective was to compare the postoperative results among patients evaluated using patient-satisfaction instruments to those evaluated using surgeon-reported scales. METHODS: Computerized database searches of MEDLINE, EMBASE, and MEDLINE In-Process were performed. Studies involving adults with cubital tunnel syndrome in whom the surgical intervention was simple decompression, anterior transposition (subcutaneous, submuscular or intramuscular), endoscopic decompression, or medial epicondylectomy were included. A systematic review was performed that included randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series. RESULTS: This systematic review of the literature identified 42 studies that satisfied the inclusion criteria. The authors identified 21 health outcomes measures used in cubital tunnel studies. These consisted of 2 generic instruments; 10 symptom-specific, author-reported instruments; 3 symptom-specific, patient-reported instruments; and 6 patient questionnaires. No measure demonstrated adequate development or validation for use in its target population. Available data revealed a consistently high level of patient satisfaction following simple decompression or submuscular transposition (65% to 92%). The results of the author-reported, symptom-specific scales varied widely and showed no obvious association with patient satisfaction. The variation in reporting of results prevented statistical comparisons between author-reported results and patient-reported results. CONCLUSIONS: To the best of our knowledge, this is the first systematic review to delineate the outcomes measures used to evaluate the treatment of cubital tunnel syndrome. Our results show that reliable, reproducible, and valid outcomes measures are lacking from the surgical literature. A standardized assessment protocol for ulnar neuropathy is required for future comparison trials. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis.

PURPOSE: Optimal surgical management of cubital tunnel syndrome remains uncertain despite the publication of numerous case series, observational studies, systematic reviews, and, in recent years, randomized controlled studies. The purpose of this meta-analysis was to compare simple decompression to anterior transposition of the ulnar nerve for the treatment of this condition, using comparative trials and randomized controlled trials. METHODS: Computerized database searches of MEDLINE, EMBASE, Cochrane Central, and all relevant surgical archives were performed. Studies involving adults with cubital tunnel syndrome in whom surgical intervention was simple decompression or anterior transposition (subcutaneous or submuscular) were included. Analysis was limited to randomized controlled trials and comparative observational studies. Included studies were assessed for quality, heterogeneity, and publication bias. Odds ratios of clinical improvement comparing simple decompression to anterior transposition (submuscular or subcutaneous) were calculated for each study. RESULTS: Ten studies involving a total of 449 simple decompressions, 342 subcutaneous transpositions, and 115 submuscular transpositions were included. There was little evidence of publication bias or statistical study heterogeneity. Odds of improvement with simple decompression versus anterior transposition were 0.751, 95% confidence interval (0.542, 1.040). Subanalyses on the basis of transposition technique (subcutaneous or submuscular) and study quality did not render a statistically significant result. CONCLUSIONS: This report represents the best cumulative evidence to date examining the surgical management of cubital tunnel syndrome. In this study, we found no statistically significant difference, but rather a trend toward an improved clinical outcome with transposition of the ulnar nerve as opposed to simple decompression. Additional prospective, randomized studies that use reproducible preoperative and postoperative objective measures might add statistical power to this finding.

Preoperative and Postoperative Assessment of Rectus Abdominis Muscle Size and Function following DIEP Flap Surgery.

BACKGROUND: Prospective evaluation of rectus abdominis muscle function after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is limited. Elimination of muscle harvest with this procedure is theoretically associated with preservation of rectus abdominis function and minimization of abdominal wall morbidity. In this study, the authors evaluate the change in rectus abdominis muscle size and function after DIEP flap surgery. METHODS: Patients undergoing unilateral DIEP flap surgery were recruited prospectively. Using computed tomography, the change in preoperative to postoperative rectus abdominis muscle size was compared between the operative side rectus abdominis muscle and the contralateral, nonoperative control rectus abdominis. Postoperative muscle integrity and contractility were evaluated using ultrasound by comparing the change in rectus abdominis muscle dimensions between contractile and relaxed states. The BREAST-Q was used to score patients' subjective satisfaction. Clinical and radiographic hernia rates were also calculated. RESULTS: Analysis of 26 paired rectus abdominis muscles revealed no significant change in muscle size from preoperative to postoperative values. Furthermore, dimensional change from contractile to relaxed states postoperatively was similar for paired operative and nonoperative rectus abdominis muscles. BREAST-Q scores indicated a high degree of satisfaction in abdominal well-being, breast satisfaction, and surgical experience domains. There were no clinical or radiographic abdominal wall hernias noted. CONCLUSIONS: The DIEP flap is an effective surgical procedure with minimal abdominal wall morbidity that is associated with no measurable loss in rectus abdominis size and contractile function postoperatively. Patients are highly satisfied with their abdominal function postoperatively using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evidence-Based Medicine: Alloplastic Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction. SUMMARY: There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Evidence-Based Medicine: Autologous Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. SUMMARY: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.