Ten-year trend analysis of breast cancer, oncoplastic, and reconstructive breast surgery in a single institution (2010-2019), what has not changed?

PURPOSE: There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period. METHODS: The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria. RESULTS: The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%. CONCLUSION: No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea.

BACKGROUND: Since April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM). METHODS: We retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into "uninsured" and "insured" groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR. RESULTS: Of 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38-48] vs. 45 [40-50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured. CONCLUSION: IBR rate in patients undergoing TM increased after NHI reimbursement.

Breast-contour preserving procedures for early-stage breast cancer: a population-based study of the trends, variation in practice and predictive characteristics in Denmark and the Netherlands.

PURPOSE: Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries. METHODS: A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries. RESULTS: BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p < 0.001) was observed in the Netherlands. In both countries, variation in BCP rates between hospitals decreased over time. NAC followed by BCT and postmastectomy IBR was substantially more often used in the Netherlands compared to Denmark, specifically in patients younger than 50 years. CONCLUSIONS: In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.

Treatment at Academic Centers Increases Likelihood of Reconstruction After Mastectomy for Breast Cancer Patients.

BACKGROUND: Mastectomy rates continue to increase in women diagnosed with breast cancer (BC). There are limited data regarding reconstruction rates at academic centers (AC) versus community hospitals (CH). We aim to determine the effect of facility type on reconstruction rates. MATERIALS AND METHODS: The National Cancer Database was queried for BC patients treated with mastectomy from 2004 to 2014. Clinical characteristics and type of reconstruction were compared between treatment at AC or CH. RESULTS: A total of 860,509 patients were included. Patients treated at AC were younger (58.7 ± 12 y AC versus 61.6 ± 13 y CH; P < 0.001) and traveled farther to their treatment center (33.1 ± 122.8 miles AC versus 20 ± 75.3 miles CH; P < 0.001). Patients undergoing surgery at AC were more likely to have reconstruction than those at CH (43.7% AC versus 32.5% CH; P < 0.001). This trend remained across all reconstruction types including expander/implant-based reconstruction (immediate breast reconstruction) (14.4% AC versus 9.9% CH), autologous reconstruction (14.9% AC versus 11.7% CH), mixed reconstruction (5.2% AC versus 3.6% CH), and other reconstructions (9.2% AC versus 7.3% CH) (all P < 0.001). Patients in all age categories, across insurance statuses, and with comorbidities were more likely to receive reconstruction if treated at AC compared with CH. In multivariate analysis, having a mastectomy at AC was an independent predictor of reconstruction (adjusted odds ratio, 1.51; 95% confidence interval, 1.49-1.51; P < 0.001). CONCLUSIONS: Undergoing mastectomy at AC results in higher rate of reconstruction compared with CH.

2020 special issue: Twenty years of breast reconstruction: Past, present, and future.

Breast reconstruction has evolved in the last 25 years to provide women with better autologous and implant-based options. The general trends of breast reconstruction have shifted to skin and nipple-areolar complex preservation, resulting in improved aesthetics and patient satisfaction. Autologous reconstruction has made a dramatic movement toward microsurgical reconstruction by free tissue transfer and has addressed lymphedema and breast sensation. Using the patient's own tissues, several aesthetic refinements have led to optimizing the cosmetic appearance of the reconstructed breast. Implant-based reconstruction has improved with the invention of form-stable silicone implants, acellular dermal matrix, and fat grafting. These positive trends will continue into the future. We hope that all women with a diagnosis of breast cancer will have the option of a consultation with a reconstructive plastic surgeon, ideally prior to undergoing resective surgery, to ensure they are aware of all reconstructive options to maximize their reconstructive result.

Surgical trends in breast cancer: a rise in novel operative treatment options over a 12 year analysis.

PURPOSE: Breast cancer surgical techniques are evolving. Few studies have analyzed national trends for the multitude of surgical options that include partial mastectomy (PM), mastectomy without reconstruction (M), mastectomy with reconstruction (M+R), and PM with oncoplastic reconstruction (OS). We hypothesize that the use of M is declining and likely correlates with the rise of surgery with reconstructive options (M+R, OS). METHODS: A retrospective cohort analysis was conducted using the ACS-NSQIP database from 2005 to 2016 and ICD codes for IBC and DCIS. Patients were then grouped together based on current procedural terminology (CPT) codes for PM, M, M+R, and OS. In each group, categories were sorted again based on additional reconstructive procedures. Data analysis was conducted via Pearson's chi-squared test for demographics, linear regression, and a non-parametric Mann- Kendall test to assess a temporal trend. RESULTS: The patient cohort consisted of 256,398 patients from the NSQIP data base; 197,387 meet inclusion criteria diagnosed with IBC or DCIS. Annual breast surgery trends changed as follows: PM 46.3-46.1% (p = 0.21), M 35.8-26.4% (p = 0.001), M+R 15.9-23.0% (p = 0.03), and OS 1.8-4.42% (p = 0.001). Analyzing the patient cohort who underwent breast conservation, categorical analysis showed a decreased use of PM alone (96-91%) with an increased use of OS (4-9%). For the patient cohort undergoing mastectomy, M alone decreased (69-53%); M+R with muscular flap decreased (9-2%); and M+R with implant placement increased (20-40%)-all three trends p < 0.0001. CONCLUSION: The modern era of breast surgery is identified by the increasing use of reconstruction for patients undergoing breast conservation (in the form of OS) and mastectomy (in the form of M+R). Our study provides data showing significant trends that will impact the future of both breast cancer surgery and breast training programs.

National Patterns of Breast Reconstruction and Nipple-Sparing Mastectomy for Breast Cancer, 2005-2015.

BACKGROUND: The purpose of this study was to explore national patterns in the uptake of breast reconstruction and nipple-sparing mastectomy (NSM). METHODS: We used the National Cancer Database to identify all women who underwent mastectomy for stage 0-III breast cancer between 2005-2015. Multivariable logistic regression was used to determine factors associated with receipt of reconstruction, with subset analyses performed to determine trends and predictors of NSM in those who underwent mastectomy with reconstruction. RESULTS: Our cohort consisted of 395,815 women, 238,568 (60.3%) who underwent mastectomy alone and 157,247 (39.7%) who underwent mastectomy followed by reconstruction. The use of breast reconstruction increased from 22.3% of mastectomy cases in 2005 to 49.7% of mastectomy cases in 2015 (odds ratio [OR] 9.7, 95% confidence interval [CI] 7.3-12.8). Among those receiving reconstruction, the use of NSM increased from 1.7% in 2005 to 14.3% in 2015 (OR 9.4, 95% CI 7.1-12.5), with increased utilization among those with early-stage and locally advanced disease, such that by 2015, NSM was performed in 15.3% of mastectomies with reconstruction for DCIS, 14.3% of mastectomies with reconstruction for stage I-II breast cancer, and 10.7% of mastectomies with reconstruction for stage III breast cancer. Factors strongly predicting receipt of NSM included age < 45 years, smaller clinical tumor size, clinically node negative disease, use of neoadjuvant therapy, and facility type. CONCLUSIONS: There has been a dramatic increase in the use of breast reconstruction and NSM between 2005-2015. Further prospective studies evaluating oncologic outcomes of NSM in locally advanced breast cancer are warranted.

Factors Leading to Decreased Rates of Immediate Postmastectomy Reconstruction.

BACKGROUND: This study was performed to determine if there was a difference in immediate breast reconstruction (IBR) rates between our public hospital and private cancer center, which share a common faculty with a consistent management philosophy in multidisciplinary care. We investigated the factors affecting postmastectomy reconstruction and IBR rates. MATERIALS AND METHODS: We retrospectively identified women with clinical stage I-II breast cancer who underwent mastectomy at our public hospital, Los Angeles County Medical Center, and our private cancer center, Keck Hospital of USC/Norris Comprehensive Cancer Center. Univariate and multivariate analyses were performed to study predictors of IBR and any breast reconstruction. RESULTS: Of 293 mastectomy patients, the rate of any breast reconstruction at the private cancer (56.6%) center was higher than that at the public hospital (36.2%). IBR rates for the private cancer center (93.6%) and for patients with private insurance were higher than for the public hospital (40.8%) and likewise for those without insurance (86.7% versus 45.5%). In a multivariate analysis, the odds of IBR at our private cancer center were 22.96 times higher than that at our public hospital. Age >50 y and radiotherapy were independent predictive factors associated with less likelihood of any breast reconstruction. CONCLUSIONS: Patients at the public hospital had a much lower rate of breast reconstruction than the private cancer center patients, even after controlling for stage and the team of treating physicians. Our results showed that older age and radiotherapy affect rates of breast reconstruction, as do hospital system and insurance status.

Poor Access to Breast Reconstruction: A Geographical Shortage of Plastic Surgeons Relative to Breast Surgeons in the United States.

BACKGROUND: Breast cancer surgery involves removal of cancer performed by a breast surgeon and reconstruction performed by a plastic surgeon. Historically, many women have not undergone breast reconstruction surgery (BRS), with current literature suggesting that geographic barriers may play a role. Our objective was to determine if there is a geographic shortage of plastic surgeons in the United States and to assess for trends in access to BRS for rural, suburban, and urban populations. METHODS: A database investigation of the 2018 membership for the American Society of Breast Surgeons and the American Society of Plastic Surgeons was performed. We searched for a breast surgeon's geographic presence by zip code and looked for the presence of a plastic surgeon within 10 and 20 miles. Zip codes were then categorized as urban, suburban, or rural. Within each population category, the average numbers of breast surgeons and plastic surgeons were quantified. RESULTS: Twenty-five percent of breast surgeon zip codes had no plastic surgeons located within 10 miles; 10% of breast surgeon zip codes had no plastic surgeon within 20 miles. There were on average 7.03 breast surgeons in each urbanized area. Suburban and rural areas had an average of 1.14 and 1.00 breast surgeons, respectively. There were on average 10.97 plastic surgeons per urbanized area. Suburban and rural areas had, on average, 0.23 and 0.06 plastic surgeons, respectively. CONCLUSIONS: A national comparison of the geographical distribution between breast surgeons and plastic surgeons indicates a shortage of plastic surgeons, especially in rural and suburban areas.

The New Trend of Pre-pectoral Breast Reconstruction: An Objective Evaluation of the Quality of Online Information for Patients Undergoing Breast Reconstruction.

The Web has increasingly become the major source of information about health care, and patients who need to undergo breast reconstruction often use the internet to acquire an initial knowledge on the subject. We would like to present our study that investigates the quality of published information on pre-pectoral breast reconstruction. We searched the term "Pre-pectoral breast reconstruction" on Google® and Yahoo®. Forty-two web sites were selected and underwent qualitative and quantitative assessment using the expanded EQIP tool. The analysis of document contents showed a critical lack of information about qualitative risks and side-effects descriptions, treatment of potential complications, alert signs for the patient and precautions that the patient may take. Health professionals should inform patients about the potential difficulties of identifying reliable informational web sites about pre-pectoral breast reconstruction. The quality of available information should be improved, especially the important topics included in the content data section of the modified EQIP tool.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Current trends of breast reconstruction after mastectomy in China: a cross-sectional study].

Objective: To investigate the current trends of breast reconstruction(BR) after mastectomy in China. Methods: A list of hospitals with more than 200 cases of breast cancer surgery per year nationwide was obtained, and 110 institutions were selected according to the geographical distribution. The research was conducted in the form of a questionnaire survey, and 92.3% (169/183) of the questions were single-choice questions. Information such as demographics of surgeons and hospitals, number of mastectomy and BR, type and timing of BR was included in the survey. Survey formal notification letter was issued by the China Anti-Cancer Association Breast Cancer Committee and Chinese College of Surgeons, Committee of Mammary Surgeons. Questionnaires were sent to the respondents of each center by email. The survey time range was from January 1, 2017 to December 31, 2017. All data were completely collected before September 7, 2018. Results: A total of 110 units participated in the survey. In total, 87.3% (96/110) of the hospitals have conducted BR surgery. The BR after mastectomy was 10.7% (6 534/61 099), among this, implant BR accounted for 65.7%(4 296/6 534), autologous BR accounted for 20.1% (1 312/6 534), and autologous combined implant BR accounted for 14.2% (927/6 534). Immediate reconstruction accounted for 67.6% (4 417/6 534) of BR, while delayed BR accounted for 32.4% (2 097/6 534). In 2017, 77.8% (35/45) of the plastic surgery departments cooperated with general surgery departments. General BR could be conducted after mastectomy accounted for 83.6% (92/110). The proportion of reconstruction was positively correlated with the gross domestic product (GDP) per capita (r=0.311, P=0.002). The one-step implant-based BR(IBBR) was the most preferred type in immediate BR. Two-step IBBR was the most preferred method in delayed BR. Hospitals that routinely evaluated aesthetics after BR accounted for 64.6% (62/96), while only 16.7% (16/96) of hospitals used patient-reported outcome measure (PROM). The most commonly used PROM tool was BREAST-Q. Conclusions: The overall BR in China is on upward trend, but gap between China and the developed countries still exists. Breast surgery departments should strengthen further cooperation with plastic surgery departments. Simultaneously, the aesthetics evaluation and PROM after BR should be put a high premium.

Racial disparities in postmastectomy breast reconstruction: National trends in utilization from 2005 to 2014.

BACKGROUND: Evidence of racial disparities in the receipt of postmastectomy breast reconstruction is well documented. The objective of this study was to describe trends in racial disparities overall and by reconstructive technique. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent mastectomy and/or breast reconstruction from 2005 to 2014. Patient demographics were recorded, and cases were grouped by reconstructive status and technique. Trends were assessed with the Cochran-Armitage test and the index of disparity. RESULTS: Over the study period, 92,960 postmastectomy patients were identified (77,049 white women, 10,396 black women, 4939 Asian women, and 576 Native American women), of whom 46,931 underwent reconstruction. Of these, 7692 women underwent autologous reconstructions (3913 free flaps and 3696 pedicled flaps). From 2005 to 2014, receipt of breast reconstruction by postmastectomy patients rose from 33.2% to 60.0%, receipt of autologous reconstruction by patients who underwent breast reconstruction fell from 30.4% to 15.9%, and receipt of free-flap reconstruction by patients who underwent autologous reconstruction rose from 15.0% to 70.8%. These trends were significant in all racial subgroups (P < .001), except for Native Americans (P = .269). The index of disparity decreased from 51.4% to 22.6% for overall receipt of breast reconstruction, decreased from 10.7% to 7.0% for tissue expander and implant-based reconstruction, increased from 18.0% to 27.3% for autologous reconstruction, and decreased from 66.7% to 4.3% for free-flap reconstruction. CONCLUSIONS: The use of postmastectomy breast reconstruction is steadily rising in the United States. Racial disparities persist, but progress has been made. Further efforts are needed to reduce racial disparities. Cancer 2018;124:2774-2784. © 2018 American Cancer Society.

Trends in Lumpectomy and Oncoplastic Breast-Conserving Surgery in the US, 2011-2016.

BACKGROUND: Oncoplastic breast surgery aims to optimize efficacy of surgical resection and cosmesis to maximize patient satisfaction; however, despite the benefits, oncoplastic techniques have not been widely adopted in the US. This study examined trends in the incidence of lumpectomy (partial mastectomy) with or without oncoplastic techniques from 2011 to 2016. METHODS: This was a retrospective analysis of claims from the Optum Clinformatics database (January 2010-March 2017). Female patients with no history of breast surgery in the prior year were categorized into three independent cohorts: isolated lumpectomy (Lx), lumpectomy with tissue transfer (LxTT), or lumpectomy with mammaplasty and/or mastopexy (LxMM). Oncoplastic techniques (in cohorts two and three) were performed at either time of the initial lumpectomy or during 90-day follow-up. RESULTS: Overall, 19,253 patients met the inclusion criteria (91.1% Lx, 5.2% LxTT, and 3.7% LxMM). Significantly fewer patients with Lx had a family history of breast cancer compared with patients with oncoplastic techniques (26.4% vs. 33.7% and 37.9%, respectively; p < 0.001). The incidence of Lx declined significantly from 2011 (92.9%) to 2016 (88.1%), while LxTT and LxMM increased from 4.2 to 7.2% and 2.8 to 4.7%, respectively (both p < 0.001). The greatest utilization of oncoplastic techniques was observed in the Pacific census division (19.2%), while lowest utilization was in the East South Central division (3.2%; p < 0.001). CONCLUSIONS: While increased adoption of oncoplastic techniques was observed, the compound annual growth rate remained below 10% and varied significantly by region. Further adoption of oncoplastic techniques is necessary to improve cosmetic outcomes and patient satisfaction following breast-conserving surgery.

Oncological safety of autologous breast reconstruction after mastectomy for invasive breast cancer.

BACKGROUND: The number of patients requesting autologous breast reconstruction (ABR) after mastectomy for breast cancer has increased over the past decades. However, concern has been expressed about the oncological safety of ABR. The aim of our study was to assess the effect of ABR on distant relapse. METHODS: In this retrospective cohort study, data was analysed from patients who underwent mastectomy for invasive breast cancer in University Hospitals Leuven between 2000 and 2011. In total, 2326 consecutive patients were included, 485 who underwent mastectomy with ABR and 1841 who underwent mastectomy alone. The risk of relapse in both groups was calculated using a Cox proportional hazards analysis, adjusted for established prognostic factors. ABR was considered as a time-dependent variable. Additionally, the evolution of the risk over follow-up time was calculated. RESULTS: With a median follow-up of 68 months, 8% of patients in the reconstruction group developed distant metastases compared to 15% in the mastectomy alone group (univariate HR 0.70, 95% CI 0.50-0.97, p = 0.0323). However, after adjustment for potential confounding factors in a Cox multivariable analysis, the risk of distant relapse was no longer significantly different between groups (multivariate HR 0.82, 95% CI 0.55-1.22, p = 0.3301). Moreover, the risk of metastasis after reconstruction was not time-dependent. CONCLUSIONS: These findings suggest that there is no effect of ABR on distant relapse rate and thus that ABR is an oncological safe procedure. The rate of local recurrence was too low to make any significant conclusions.

Breast Reconstruction: A Century of Controversies and Progress.

Breast cancer treatment has dramatically changed over the past century. Since Halsted's first description of radical mastectomy in 1882, breast reconstruction has evolved slowly from being considered as a useless or even dangerous procedure by surgeons to the possibility nowadays of reconstructing almost any kind of defect. In this review on the development of breast reconstruction, we outline the historical milestone innovations that led to the current management of the mastectomy defect in an attempt to understand the economic, social and psychological factors, which contributed to slow down its acceptance for several decades.

Oncoplastic and reconstructive breast surgery in Canada: breaking new ground in general surgical training

Summary: Oncoplastic breast surgery combines certain plastic surgery procedures with a breast cancer resection to minimize the cosmetic penalty. We compared current practices in breast surgery in Canada and the UK, looking at the classification of oncoplastic breast surgery, management of larger tumours that would otherwise mandate a mastectomy, and the breast surgeon's role in immediate breast reconstruction. Reconstructive breast surgery has always fallen within the domain of the plastic surgeon, but surgical subspecialization and more focused fellowship training have meant that breast surgeons with the appropriate skillset can offer these procedures. This evolution of the breast surgeon has led to the birth of a new field of breast surgery known as oncoplastic and reconstructive breast surgery. Those tasked with developing surgical training programs in Canada must now decide whether to train breast surgeons in these techniques to improve long-term quality of life among Canadian patients with breast cancer.

The Evolution of Breast Reduction Publications: A Bibliometric Analysis.

OBJECTIVE: This study aims to make a bibliometric analysis of the studies on breast reduction (BR) between the years 1980 and 2016 and identify important studies through trend topics as well as active authors, countries, universities, scientific journals, and citation and co-citation analyses about BR. BACKGROUND: Although BR looks like one of the cosmetic surgeries performed in order to restore the woman's appearance, in fact it is a reconstructive surgery that eliminates back pain, stance disorder, headache, shoulder pain, back and cervical disk hernia, difficulty in breathing, hollowness caused by bra straps, hygiene problems under breasts (e.g., rash or fungal infections), and limitations in some daily activities. However, the related literature has little information about the publications on this issue. METHODS: Bibliometric analysis was performed by downloading all the documents published between 1980 and 2016 from Thomson Reuters Web of Science (WoS; Thomson Reuters, New York, NY, USA), using the keywords including "breast reduction", "gigantomastia", "reduction mammaplasty", and "reduction mammoplasty". RESULTS: There was a total of 1427 publications in the WoS database. Of these publications, 869 (60.90%) were research articles. The top three research areas of these publications were surgery with 1178 (82.55%) publications, oncology with 78 (5.47%) publications, and obstetrics gynecology with 67 (4.70%) publications. The top three countries that contributed to the literature most were the USA (515), England (147), and Turkey (83), respectively; the top university that contributed most was Harvard University, and the top two authors who contributed most were Drew PJ and Iwuagwu OC (13; 0.91%). The top-cited publication was "A Simplified Vertical Reduction Mammaplasty: Shortening the Learning Curve" written by Hall-Findlay, EJ in 1999. The journals with top numbers of publications were Plastic and Reconstructive Surgery (483; 33.85%), Annals of Plastic Surgery (164; 11.50%) and Aesthetic Plastic Surgery (147; 10.30%) respectively. CONCLUSION: Despite the fact that the BR literature is contributed by developed countries, developing countries, particularly Turkey and Brazil, also had significant contributions to the literature. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Public Interest in Breast Augmentation: Analysis and Implications of Google Trends Data.

INTRODUCTION: Breast augmentation is the most common aesthetic surgery performed in the United States (US) annually. Analysis of Google Trends (GT) data may give plastic surgeons useful information regarding worldwide, national, and regional interest for breast augmentation and other commonly performed aesthetic surgeries. METHODS: Data were collected using GT for breast augmentation and associated search terms from January 2004 to May 2017. Case volume was obtained from the American Society of Plastic Surgeons (ASPS) annual reports for the calendar year 2005-2016. RESULTS: Trend analysis showed that total search term volume for breast augmentation and breast implants gradually decreased worldwide and in the US over the study period while the search term boob job slowly increased. Univariate linear regression demonstrated a statistically significant positive correlation between average annual Google search volume of "breast augmentation" and the annual volume of breast augmentations performed in the US according to ASPS data (R 2 = 0.44, p = 0.018). There was no significant correlation between national volume of breast augmentations performed and search volume using the terms "breast implants" or "boob job" over time (p = 0.84 and p = 0.07, respectively). In addition, there appears to be country specific variation in interest based on time of year and peaks in interest following specific policies. CONCLUSIONS: To our knowledge, this is the first and only analysis of GT data in the plastic surgery literature to date. To that end, this study highlights this large and potentially powerful data set for plastic surgeons both in the US and around the world. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trends in Post-Mastectomy Reconstruction in an Asian Population: A 12-Year Institutional Review.

Post-mastectomy breast reconstruction is an integral component of breast cancer treatment. It is often perceived that women in Asian countries have a lower rate of post-mastectomy reconstruction than Western populations. This study describes trends in timing and types of breast reconstruction performed in the largest healthcare provider in Singapore, over a period of 12 years. It also reports on the oncological outcomes and surgical safety. A retrospective review of all patients who underwent post-mastectomy reconstruction from January 2001 to December 2012 at the National Cancer Centre Singapore and Singapore General Hospital was performed. Six hundred and twenty post-mastectomy reconstructions were performed in 579 patients. The proportion of reconstructions increased from 4% in 2001 to 18% in 2012. Younger patients (<50 years old) and those with early stage cancer were more likely to undergo reconstruction. Immediate breast reconstruction was favored by more than 90% of patients. Postoperatively, 9% developed acute surgical complications that were treated surgically; 6% had additional surgery for late complications. Only 4% had delay of adjuvant chemotherapy. At median follow-up of 63 months (range 3-166), loco-regional recurrence was 4%, and distant metastases 8%. Post-mastectomy reconstruction for breast cancer is increasingly performed in our institution. Both younger age and lower stage disease were associated with choice for reconstruction in our study. Low rates of delay to adjuvant therapy were noted, and it may safely be offered to suitable women undergoing mastectomy.

Does Demand for Breast Augmentation Reflect National Financial Trends?

Aesthetic plastic surgery is a consumer-driven industry, subject to influence by financial forces. A changing economic environment may thus impact on the demand for surgery. The aim of this study was to explore trends in demand for bilateral breast augmentation (BBA) in consecutively presenting patients over an 11-year period and to examine if a correlation exists between these trends and changes in Gross Domestic Product (GDP), a key economic indicator. This study revealed a correlation between annual number of breast augmentation procedures performed and GDP values (r 2 = 0.34, p value = 0.059). Additionally, predicted number of BBA procedures, based on predicted GDP growth in Ireland, strongly correlated with actual number of BBA performed (r 2 = 0.93, p value = 0.000001). Predicted GDP growth can potentially forecast future demand for BBA in our cohort allowing plastic surgeons to modify their practice accordingly. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .