Deep learning-based risk stratification of preoperative breast biopsies using digital whole slide images.

BACKGROUND: Nottingham histological grade (NHG) is a well established prognostic factor in breast cancer histopathology but has a high inter-assessor variability with many tumours being classified as intermediate grade, NHG2. Here, we evaluate if DeepGrade, a previously developed model for risk stratification of resected tumour specimens, could be applied to risk-stratify tumour biopsy specimens. METHODS: A total of 11,955,755 tiles from 1169 whole slide images of preoperative biopsies from 896 patients diagnosed with breast cancer in Stockholm, Sweden, were included. DeepGrade, a deep convolutional neural network model, was applied for the prediction of low- and high-risk tumours. It was evaluated against clinically assigned grades NHG1 and NHG3 on the biopsy specimen but also against the grades assigned to the corresponding resection specimen using area under the operating curve (AUC). The prognostic value of the DeepGrade model in the biopsy setting was evaluated using time-to-event analysis. RESULTS: Based on preoperative biopsy images, the DeepGrade model predicted resected tumour cases of clinical grades NHG1 and NHG3 with an AUC of 0.908 (95% CI: 0.88; 0.93). Furthermore, out of the 432 resected clinically-assigned NHG2 tumours, 281 (65%) were classified as DeepGrade-low and 151 (35%) as DeepGrade-high. Using a multivariable Cox proportional hazards model the hazard ratio between DeepGrade low- and high-risk groups was estimated as 2.01 (95% CI: 1.06; 3.79). CONCLUSIONS: DeepGrade provided prediction of tumour grades NHG1 and NHG3 on the resection specimen using only the biopsy specimen. The results demonstrate that the DeepGrade model can provide decision support to identify high-risk tumours based on preoperative biopsies, thus improving early treatment decisions.

Effectiveness and toxicity of five-fraction prone accelerated partial breast irradiation.

PURPOSE: Our institution was an early adopter of 5-fraction accelerated partial breast irradiation (ABPI) to treat women with early-stage breast cancer. This study reports long-term oncologic and cosmetic outcomes. METHODS: We included patients receiving APBI 600 cGy × 5 fx delivered every other day or every day between 2010 and 2022. Logistic regression models were used to identify factors associated with development of late toxicities, clinician, and patient-rated cosmesis. Kaplan-Meier methodology was used to calculate overall survival (OS), disease-free survival (DFS), and locoregional recurrence-free survival (LR-RFS). RESULTS: 442 patients received APBI either daily (56%) or every other day (44%) in the prone position (92%). At a median follow-up of 48 months (range: 5.96-155 months), 12 (2.7%) patients developed a local recurrence (LR). Out of 258 patients with > 3-month toxicity data available, the most common late grade ≥ 2 adverse event was breast fibrosis (6.2%). On multivariate analysis, daily APBI treatment (vs every other day) did not correlate with an increased risk of any late grade ≥ 2 toxicity though it did correlate with a lower risk of any late grade ≥ 2 fibrosis. Overall, at a median follow-up of 80 months, the rates of good-excellent physician and patient-rated cosmesis were 95% and 85%, respectively, with no difference between patients treated on consecutive vs. every other day. On multivariate analysis, patients who did not receive any adjuvant therapy were at increased risk of developing a LR. Five-year OS, LRFS, and DFS were 97.2%, 97.7%, and 89.5%, respectively. CONCLUSIONS: Five-fraction APBI delivered primarily in the prone position either daily or every other day was effective with low rates of local recurrence, minimal toxicity, and excellent cosmesis at long-term follow-up.

Impact of pre-operative MRI on surgical management of screening digital breast tomosynthesis-detected invasive lobular carcinoma.

PURPOSE: The purpose of this study is to determine the impact of pre-operative MRI on surgical management of screening digital breast tomosynthesis (DBT)-detected invasive lobular carcinoma (ILC). METHODS: A retrospective medical record analysis was conducted of women with screening DBT-detected ILC and subsequent surgery from 2017-2021. Clinical, imaging, and pathological features were compared between women who did and did not undergo MRI, and between women with and without additional disease detected on MRI, using the Pearson's chi-squared test and Wilcoxon signed-rank test. Concordance between imaging and surgical pathology sizes was also evaluated. RESULTS: Of 125 women (mean age 67 years, range 44-90) with screening-detected ILC, MRI was obtained in 62 women (49.6%) with a mean age of 63 years (range 45-80). Compared to women without MRI, women who had MRI examinations were younger, more likely to have dense breast tissue, and more likely to undergo mastectomy initially rather than lumpectomy (p < 0.001-0.01). Eighteen biopsies were performed based on MRI findings, of which 55.6% (10/18) were malignant. Conventional imaging more frequently underestimated ILC span at the biopsy site than MRI, using a 25% threshold difference (17.5% [7/40] versus 58.5% [24/41], p < 0.001). MRI detected more extensive disease at the biopsy site in six patients (9.7%, 6/62), additional ipsilateral disease in six patients (9.7%, 6/62), and contralateral disease in one patient (1.6%, 1/62). MRI therefore impacted surgical management in 21.0% (13/62) of patients. CONCLUSION: MRI led to the detection of additional disease, thus impacting surgical management, in one-fifth of patients with ILC.

De-escalating indications for excision when breast core needle biopsy returns fibroepithelial lesion-not further characterized.

PURPOSE: Surgical excision is often performed to exclude phyllodes tumor (PT) when Core Needle Biopsy (CNB) of the breast returns fibroepithelial lesion-not further characterized (FEL-NFC). If imaging or CNB pathology features can be identified that predict a very low probability of borderline/malignant PT, thousands of women could be spared the expense and morbidity of surgical excisions. METHODS: This retrospective cohort study includes 180 FEL-NFC from 164 patients who underwent surgical excisional biopsy. RESULTS: The upgrade rate from FEL-NFC to benign PT was 15%, and to borderline/malignant PT 7%. Imaging features predicting upgrade to borderline/malignant PT included greater size (p = 0.0002) and heterogeneous echo pattern on sonography (p = 0.117). Histologic features of CNB predicting upgrade to borderline/malignant PT included "pathologist favors PT" (p = 0.012), mitoses (p = 0.014), stromal overgrowth (p = 0.006), increased cellularity (p = 0.0001) and leaf-like architecture (p = 0.077). A three-component score including size > 4.5 cm (Size), heterogeneous echo pattern on sonography (Heterogeneity), and stromal overgrowth on CNB (Overgrowth) maximized the product of sensitivity x specificity for the prediction of borderline/malignant PT. When the SHO score was 0 (72% of FEL-NFC) the probability of borderline/malignant PT on excision was only 1%. CONCLUSION: The combination of size ≤ 4.5 cm, homogeneous echo pattern, and absence of stromal overgrowth is highly predictive of a benign excision potentially sparing most patients diagnosed with FEL-NFC the expense and morbidity of a surgical excision.

A BRILLIANT-BRCA study: residual breast tissue after mastectomy and reconstruction.

INTRODUCTION: Different types of mastectomies leave different amounts of residual breast tissue. The significance of the residual breast volume (RBV) is not clear. Therefore, we developed an MRI tool that allows to easily assess the RBV. In this study we evaluated factors associated with RBV after skin or nipple sparing mastectomy (SSM/NSM) in breast cancer BRCA pathogenic variant (PV) carriers who underwent both therapeutic and risk reducing SSM/NSM and its relation to breast cancer outcomes using an innovative MRI-based tool. METHODS: Data of breast cancer BRCA PV who were treated between 2006 and 2020 were retrieved from of the oncogenetics unit databases. Only patients who underwent SSM/NSM and had a postoperative breast MRI available for analysis were included. Data collected included demographics, clinicopathological features, and outcomes. The MRI tool was developed by a breast cancer imaging laboratory. A logistic regression test and 95% confidence interval (CI) were used to assess the associated risk of increased RBV. A forward stepwise linear regression was used to correlate tumour-patient specific factors and RBV, and a Kaplan-Meier curve to show the probability of locoregional relapse. RESULTS: A total of 84 patients undergoing 89 mastectomies were included. At a median follow-up of 98 months, 5 local, 2 regional, and 4 distant recurrences were observed. RBV was not significantly related with breast cancer outcomes (p value = NS). A higher body mass index (BMI) was associated with a higher RBV (p < 0.0001). A larger number of involved axillary nodes was associated with a smaller RBV (p = 0.025). The RBV on the risk-reducing mastectomy side was significantly higher compared to the breast cancer side (p value = 0.007). Local recurrences occurred in the vicinity of the primary tumour.

Reducing re-excision rates in breast conserving surgery with Margin Probe: systematic review.

INTRODUCTION: Different intraoperative techniques with varying levels of evidence are available to decrease positive surgical margins during breast conserving surgery. The aim of this review is to assess the effectiveness of the MarginProbe® device as an intraoperative adjunct tool in reducing positive surgical margins, and subsequently exploring the effect on patient re-excision rates. METHODOLOGY: A systematic review of the available medical literature was conducted from 2007 to March 2022. A literature search of Cochrane, PubMed and Embase by two independent reviewers reviwers was performed to identify eligible articles looking at the primary outcome of percentage reduction in patient re-excision rates using MarginProbe®. Secondary outcomes analysed were comparison of tissue volume removed, absolute and relative reduction in re-excision rate, cosmetic outcome, as well as MarginProbe® sensitivity and specificity. RESULTS: A total of 12 full text articles were identified. An independent samples t-test using a total of 2680 patients found a 54.68 per cent reduction in re-excision rate with the use of MarginProbe®, which was statistically significant with a large effect size (P < 0.001; d = 1.826). Secondary outcomes showed a relatively higher sensitivity of the MarginProbe® device, at the expense of decreased specificity, and no significant impact on cosmesis and volume of breast tissue excised. CONCLUSION: MarginProbe® is an effective intraoperative adjunct in breast-conservation surgery that reduces patient re-excision rates, with no adverse effects relating to breast cosmesis or increase in volume of excised tissue.

Radial sclerosing lesions found on core needle biopsy: excision can be safely avoided.

AIMS: Radial sclerosing lesions (RSLs) are benign breast lesions composed of glandular and epithelial proliferations with stellate architecture and fibro-elastotic stroma, which can mimic invasive carcinoma on imaging. Surgical management following a core biopsy diagnosis of RSLs remains controversial. METHODS AND RESULTS: We retrospectively identified core biopsies with RSLs without atypia who underwent subsequent surgical excision between 2015 and 2021. All core biopsy slides were reviewed to confirm the diagnosis. Imaging was reviewed to determine radiological-pathological concordance. An upgrade was defined as invasive carcinoma or ductal carcinoma in situ (DCIS) in the excision. The final cohort consisted of 130 core biopsies from 124 women (median age = 52 years, range = 27-76). The imaging modality was mammogram in 52 (40%) cases, MRI in 52 (40%) and ultrasound in 26 (20%). One hundred and seven (82%) core biopsies were vacuum-assisted and 23 (18%) were ultrasound-guided without vacuum assistance. The median lesion size on imaging was 9 mm (range = 2-41). Overall, two (1%) cases were upgraded at excision, including one microinvasive lobular carcinoma and one 2 mm focus of invasive mammary carcinoma with associated DCIS. In both cases, the upgraded foci of carcinoma were not closely associated with the biopsy site and were considered incidental upgrades. CONCLUSIONS: This study adds to the body of literature supporting observation, rather than routine excision of radial sclerosing lesions without atypia.

Risk factors for residual fibroglandular breast tissue following a mastectomy - an overview and retrospective cohort study.

BACKGROUND: Residual fibroglandular breast tissue (RFGT) following a mastectomy is associated with the remaining of occult breast cancer at the time of mastectomy as well as an increased local recurrence risk thereafter. Despite its oncologic implications, data on measures to prevent RFGT are lacking. Therefore, in a first step knowledge of risk factors for RFGT is of uttermost importance in order to allow identification of patients at risk and subsequently adaption of the surgical treatment and potentially prevention of RFGT a priori. METHODS: We performed a systematic literature review in PubMed using the MESH terms [residual fibroglandular breast tissue], [residual breast tissue], [mastectomy] and [risk factor] followed by a retrospective data analysis including all patients with a mastectomy treated at the Department of Obstetrics and Gynecology of the Medical University of Vienna, Austria, between 01.01.2015 and 26.02.2020 in order to identify risk factors of RFGT following a mastectomy. The primary aim of the study was to assess a potential difference in RFGT volume between the different types of mastectomy. The secondary objectives of the study were to identify other potential risk factors for RFGT as well as to compare the skin and subcutaneous fat tissue thickness pre- to postoperatively. RESULTS: Significantly higher RFGT volumes were observed following a nipple-sparing mastectomy (NSM) compared to a skin-sparing mastectomy (SSM) and radical mastectomy (RME) (p < .001). Furthermore, RFGT volume was significantly associated with the variables: reconstruction (p = .012), acellular dermal matrix (ADM) or mesh (p = .031), patient age (p = .022), preoperative fibroglandular tissue (FGT) volume (p = .012) and preoperative whole breast volume (including the skin envelope and nipple-areola-complex) (p = .030). The reduction in the postoperative compared to preoperative skin envelope thickness measured medially and laterally reached statistical significance in the NSM-cohort (medial p < .001, lateral p = .001) and showed a numerical difference in the RME and SSM-cohort. CONCLUSION: Mastectomy type, reconstruction, ADM or mesh, patient age, preoperative FGT volume and whole breast volume were identified as risk factors for RFGT in univariable analysis. The observed reduction in the post- compared to preoperative skin envelope thickness should be avoided considering the known associated increase in risk for ischemic complications.

Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study.

OBJECTIVE: The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio. METHODS: We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed. RESULTS: Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8 mm, p = 0.019). CONCLUSIONS: Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy. CLINICAL RELEVANCE STATEMENT: Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions. KEY POINTS: • Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

Successful Use of a Cadaver Model to Teach Ultrasound-Guided Breast Procedures to Surgical Trainees.

INTRODUCTION: In academic breast surgery, ultrasound use tends to be limited to radiology departments, thus formal surgical resident training in breast ultrasound is sparse. Building on residents' ultrasound skills in our general surgery training program, we developed a novel curriculum to teach ultrasound-guided breast procedures (UGBPs), including core needle biopsy (CNB) and wire localization (WL). We hypothesized that learning UGBPs on cadavers would be preferred to learning with a breast phantom model using chicken breasts. METHODS: Residents received a 1-h lecture on breast CNB and WL followed by a 1-h hands-on laboratory session. Olives stuffed with red pimentos were used to replicate breast masses and implanted in chicken breasts and the breasts of lightly embalmed and unembalmed female cadavers. All residents practiced UGBPs with a course instructor on both models. Residents completed anonymous prelaboratory and postlaboratory surveys utilizing five-point Likert scales. RESULTS: A total of 35 trainees participated in the didactics; all completed the prelaboratory survey and 28 completed the postlaboratory survey. Participant clinical year ranged from 1 to 6. Residents' confidence in describing and performing CNBs and WLs increased significantly on postlaboratory surveys, controlling for clinical year (P < 0.001). Eighty-point seven percent preferred learning UGBPs on cadavers over phantoms most commonly citing that the cadaver was more realistic. CONCLUSIONS: Following a novel 2-h UGBP training curriculum using phantom and cadaveric models, resident confidence in describing and performing UGBPs significantly improved. Most favored the cadaveric model and reported that the course prepared them for real-life procedures.

B3 Breast Lesions: Positive Predictive Value and Follow-Up on a Large Single-Institution Series.

INTRODUCTION: Lesions of uncertain malignant potential (B3) represent 10% of core needle biopsies (CNBs) or vacuum-assisted breast biopsies (VABBs). Traditionally, B3 lesions are operated on. This study investigated the association between B3 subtypes and malignancy to determine the best management. METHODS: Pre- and postoperative histological reports from 226 patients, who had undergone excisional surgery for B3 lesions, following CNB or VABB, were retrospectively analyzed. The correlation between the CNB/VABB diagnosis and the final pathology was investigated, along with the correlation between malignancy upgrade and the type of mammographic lesion. The positive predictive value (PPV) of malignancy of B3 lesions was calculated by simple logistic regression. Patients without cancer diagnosis underwent a 7-y follow-up. RESULTS: Pathology showed 171 (75.6%) benign and 55 (24.3%) malignant lesions. The PPV was 24.3% (P = 0.043), including 31 (13.7%) ductal carcinomas in situ and 24 (10.6%) invasive carcinomas. The most frequently upgraded lesions were atypical ductal hyperplasia, 34.2% (P = 0.004), followed by lobular intraepithelial neoplasia, 27.5% (P = 0.025). The median diameter of mammographic lesions was 1.5 [0.9-2.5] cm, while for surgical specimens, it was 5 [4-7] cm (P < 0.0001). Mammographic findings and histology showed a significant correlation (P = 0.038). After a 7-y follow-up, 15 (8.9%) patients developed carcinoma, and 7 patients (4%) developed a new B3 lesion. CONCLUSIONS: We can conclude that atypical ductal hyperplasia and lobular intraepithelial neoplasia still require surgery for a significant PPV. Other types that lacked significance or confidence intervals were too wide to draw any conclusion.

Rates of breast reconstruction uptake and attitudes toward breast cancer and survivorship among south asians: A literature review.

Our aim in this review was to ascertain rates of breast reconstruction among South Asian patients and identify attitudes towards breast cancer, survivorship, and breast reconstruction. Mastectomy rates for South Asian patients ranged from 52% to 77% and reconstruction following mastectomy varied from 0% to 14%. A negative perception of cancer, fears of social isolation, and taboos around breasts can prevent South Asian women from receiving surgical care after a breast cancer diagnosis.

Impact of autologous breast reconstruction on bra fit.

PURPOSE: To inform bra design by analyzing 3D surface images of breast cancer patients who underwent autologous breast reconstruction. METHODS: We computed bra design measurements on 3D surface images of patients who underwent unilateral and bilateral autologous breast reconstruction. Breast measurements and right-left symmetry between preoperative baseline and postoperative time points were compared using either paired Student t-test or Wilcoxon signed-rank test, depending on the data's distribution. Regression analysis determined associations between measurements and patient characteristics such as age. Postoperative measurements and symmetry differences were also compared between autologous and implant-based breast reconstruction. RESULTS: Among participants who underwent bilateral autologous breast reconstruction, the reconstructed breasts were smaller and positioned higher on the chest wall than their native breasts. For patients who underwent unilateral reconstruction, similar postoperative changes were observed in the contralateral breast due to symmetry procedures. Overall, for participants whose baseline breast measurements showed substantial asymmetry, unilateral reconstruction decreased right-left asymmetry whereas bilateral reconstruction amplified right-left asymmetry. Preoperative baseline breast measurements, age, and BMI were statistically significantly associated with most postoperative breast measurements for participants who underwent bilateral autologous reconstruction. Compared to implant-based reconstruction, autologous reconstruction resulted in fewer changes in breast shape and symmetry that are pertinent to bra fit. CONCLUSION: Preoperative baseline breast measurements, age, and BMI can impact bra designs for breast cancer survivors who undergo autologous reconstruction due to size, shape, and symmetry changes. Bra needs of people who undergo autologous reconstruction differ from those who undergo implant-based reconstruction.

Results of shared learning of a new radiofrequency identification localization device-a UK iBRA-NET breast cancer localisation study.

INTRODUCTION: Localisation methods for surgical excision of impalpable breast lesions have advanced in recent years, with increasing utilization of new wire-free technologies. The Hologic LOCalizer™ radiofrequency identification (RFID) tag is one such device; however, as is the case when new technologies are first introduced, little is known about clinical experiences, potential complications, and learning used to overcome perioperative challenges when changing from guidewires to RFID tags. This study reports shared learning experiences of clinicians using the LOCalizer™ as part of the national iBRA-NET localisation study. METHODS: This mixed-methods study captured shared-learning themes relating to LOCalizer™ usage as part of a multicentre prospective registry study, which collected data on each LOCalizer™ placement. Prospective, anonymized clinical and demographic data were collected and managed using a Research Electronic Data Capture (REDCap) database. Shared learning was captured prospectively as part of the registry study between January 2021 and July 2022, combined with a virtual qualitative webinar-style focus group. Learning events were then coded, grouped by theme, and suggestions for practice were produced. RESULTS: Twenty-four UK breast units submitted data on 1188 patient records pertaining to RFID-guided localisation between January 2021 and July 2022, of which 59 (5.0%) included a shared-learning event. The virtual webinar was attended by 108 healthcare professionals, including oncoplastic breast surgeons and breast radiologists. Shared-learning themes were categorized into preoperative, intraoperative, and postoperative events. CONCLUSIONS: By sharing learning outcomes associated with localisation techniques in this paper, the aim is to shorten the learning curve and potential for adverse events for users new to the LOCalizer™ technique.

Mammoplasty Using Modified Superomedial Pedicle Technique in Severely Macromastia and Ptotic Breasts.

Mammoplasty is a surgery commonly used for macromastia. Many mammoplasty techniques are described, all with their specific pros and cons. However, the concern to avoid serious complications sometimes takes precedence, and the ideal result cannot be. For macromastia and severely ptotic breasts, usually the free nipple-areolar complex (NAC) mammoplasty technique is implemented. The results, however, may only be completely satisfactory regarding cosmetics. Loss of NAC, poor appearance, flabbiness, flattening, and ptosis are among the disadvantages of this technique. This study aimed to present the results of mammoplasty employing the superomedial pedicle technique without interrupting a macromastia central base with a pedicle length of 8 to 18 cm. According to the literature, many plastic surgeons recommend the free NAC rather than the pedicle technique because of the high complication rates in mammoplasties planned for highly ptotic breasts and macromastia. On the other hand, many free NAC techniques and their modifications with pedicle mammoplasty are described. The general conviction is that a standard method, protocol, or technique good for all patients does not exist. Our results are more acceptable both cosmetically and physiologically. Therefore, the superomedial pedicle technique can be modified to achieve ideal results where free NAC mammoplasty is considered for severe macromastia and ptotic patients. This combined method contributes to the viability of NAC by increasing blood supply to breast tissue and providing an ideal breast appearance.

Resection Weight Formulas for Reduction Mammoplasty: A Systematic Review and Regression Analysis.

PURPOSE: Estimating resection weight for patients undergoing reduction mammoplasty (RM) informs surgical planning and outcomes. Existing formulas have limitations that make insurance coverage and accurate surgical planning challenging. We identified the most commonly used scales to evaluate their accuracy in estimating resection weight by applying them to a database of patients to compare calculated and actual resection weights. METHODS: A database search was conducted using combinations of relevant terms. A regression analysis was conducted using formulas with strong R2 values (0.72-0.93) on a cohort of 1128 RM patients at a single institution. RESULTS: A total of 570 articles were identified. Fourteen manuscripts (n = 2232 patients [3320 breasts]) were ultimately included for review. Data on incisional patterns, pedicle supply, and breast measurements, such as sternal notch to nipple distance (n = 8 [57.1%]) or nipple to inframammary fold distance (n = 5 [35.7%]), were recorded. R2 values in our cohort (>500 g, n = 891; <500 g, n = 237) were calculated via regression analyses with five formulas: Appel (0.391 vs 0.146), Boukovalas (0.3552 vs 0.043), Descamps (0.391 vs 0.238), Eder (0.328 vs 0.114), and Kocak (0.3283 vs R2 indeterminate). CONCLUSIONS: Our analysis suggests that formulas reporting strong R2 values may have resulted from tailoring to surgeons' technique. Variation between cohorts is inevitable; however, we expect reliable results given our large sample. It is reasonable to conclude that existing formulas are not accurate representations of resection weights and thus are unreliable for surgical planning.

Predicting Reduction Mammaplasty Total Resection Weight With Machine Learning.

BACKGROUND: Machine learning (ML) is a form of artificial intelligence that has been used to create better predictive models in medicine. Using ML algorithms, we sought to create a predictive model for breast resection weight based on anthropometric measurements. METHODS: We analyzed 237 patients (474 individual breasts) who underwent reduction mammoplasty at our institution. Anthropometric variables included body surface area (BSA), body mass index, sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold values. Four different ML algorithms (linear regression, ridge regression, support vector regression, and random forest regression) either including or excluding the Schnur Scale prediction for the same data were trained and tested on their ability to recognize the relationship between the anthropometric variables and total resection weights. Resection weight prediction accuracy for each model and the Schnur scale alone were evaluated based on using mean absolute error (MAE). RESULTS: In our cohort, mean age was 40.36 years. Most patients (71.61%) were African American. Mean BSA was 2.0 m 2 , mean body mass index was 33.045 kg/m 2 , mean SN-N was 35.0 cm, and mean nipple-to-inframammary fold was 16.0 cm. Mean SN-N was found to have the greatest variable importance. All 4 models made resection weight predictions with MAE lower than that of the Schnur Scale alone in both the training and testing datasets. Overall, the random forest regression model without Schnur scale weight had the lowest MAE at 186.20. CONCLUSION: Our ML resection weight prediction model represents an accurate and promising alternative to the Schnur Scale in the setting of reduction mammaplasty consultations.

Two-Stage Surgical Management of Accessory Breast Tissue With Pedicled Breast Tissue: A Case Report of Asymmetry Correction.

ABSTRACT: Accessory breast tissue is a relatively common variant of ectopic breast tissue. It defines a tissue that can be seen in conjunction with a nipple, areola, and underlying glandular tissues and can develop in addition to the normal breast tissue. While swelling may be accompanied by symptoms such as pain that worsens with the menstrual period, lactation, and limitation of shoulder joint movements, aesthetic concerns also constitute an important part of the surgical needs of patients. An 18-year-old patient without any known comorbidities attended because of a developmental disorder in her left breast that has existed since birth and an accessory breast tissue containing the nipple and areola in the upper-outer quadrant of the left breast. The surgical aim was to excise the patient's accessory breast tissue and ensure symmetry, and a two-stage surgical intervention was planned. In the first stage, the accessory breast tissue in the upper-outer quadrant of the breast was transposed preserving the 2nd and 3rd Internal Mammary Artery-based perforators by passing it through a subcutaneous tunnel and folding it in its ideal place. At second stage, the reduction mammoplasty surgery was performed on the right breast to ensure symmetry with the left breast, and resection was performed on the nipple in the middle lower quadrant of the left breast. At the end, acceptable symmetry and patient satisfaction were achieved.

Vertical Scar Reduction Mammaplasty Using the Superomedial-Based Pedicle Technique in Gigantomastia.

BACKGROUND: Breast reduction surgery has witnessed significant advancements in recent years; however, it continues to pose challenges for both surgeons and patients when dealing with cases involving excessive breast volume and severe breast ptosis. This study aimed to assess the aesthetic outcomes and the impact on the quality of life, as measured by the BREAST-Q questionnaire, in patients with gigantomastia and severe breast ptosis who underwent reduction mammaplasty using the superomedial-based pedicle technique. METHODS: We present a retrospective series comprising 84 patients who underwent reduction mammoplasty utilizing the superomedial pedicle technique. The surgical resections exceeded 1 kg per breast, with a mean resection weight of 1506.58 g (right breast) and 1500.32 g (left breast). The preoperative mean suprasternal notch to nipple distance measured 40.50 cm (right breast) and 40.38 cm (left breast). Postoperatively, the patients were followed up for a minimum of 6 months. Both preoperative and postoperative BREAST-Q surveys were administered to the participants, and scores were analyzed using descriptive statistics. RESULTS: Complications were observed in 3 patients (3.57%), characterized by partial loss of the areola, which resolved spontaneously over time. Additionally, 2 cases of hematoma and 2 instances of minor delayed wound healing were reported. All patients expressed satisfaction with their aesthetic outcomes, as they achieved a natural breast shape and minimal scarring, along with symptomatic relief. CONCLUSIONS: The superomedial pedicle reduction mammaplasty technique has demonstrated its ability to produce satisfactory aesthetic outcomes and long-term benefits in patients with excessively large breasts. Careful patient selection and postoperative management are vital for achieving optimal results. Further investigations involving larger sample sizes and longer follow-up periods are warranted to validate our findings. LEVEL OF EVIDENCE: IV.

A Scoping Review of Innervated Breast Reconstruction.

BACKGROUND: After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction. METHODS: The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel. RESULTS: From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction. CONCLUSIONS: Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.