RESUMEN
BACKGROUND: Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. METHODS: NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. RESULTS: A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. CONCLUSIONS: Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.
Asunto(s)
Neoplasias de la Mama , Carcinoma Intraductal no Infiltrante , Márgenes de Escisión , Recurrencia Local de Neoplasia , Pezones , Tratamientos Conservadores del Órgano , Humanos , Femenino , Pezones/cirugía , Pezones/patología , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/patología , Persona de Mediana Edad , Carcinoma Intraductal no Infiltrante/cirugía , Carcinoma Intraductal no Infiltrante/patología , Recurrencia Local de Neoplasia/cirugía , Recurrencia Local de Neoplasia/patología , Estudios de Seguimiento , Adulto , Tratamientos Conservadores del Órgano/métodos , Carcinoma Ductal de Mama/cirugía , Carcinoma Ductal de Mama/patología , Pronóstico , Tasa de Supervivencia , Anciano , Estudios Prospectivos , Mastectomía Subcutánea/métodos , Invasividad Neoplásica , Neoplasia Residual/cirugía , Neoplasia Residual/patologíaRESUMEN
For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Femenino , Humanos , Implantes de Mama/efectos adversos , Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/cirugía , Mamoplastia/efectos adversos , Mamoplastia/métodos , Mastectomía/efectos adversos , Mastectomía/métodos , Recurrencia Local de Neoplasia/diagnóstico por imagen , Pezones , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Patients seeking cosmetic abdominoplasty often have umbilical hernias. Optimal management and safety of concomitant umbilical hernia repair with abdominoplasty is not well described. OBJECTIVES: The goal of this study was to compare complication rates following abdominoplasty with or without umbilical hernia repair. METHODS: A retrospective propensity score matched cohort study of patients who underwent an abdominoplasty at Massachusetts General Hospital was performed. Direct umbilical hernia repair was performed by making a fascial slit inferior or superior to the umbilical stalk. The fascial edges were approximated with up to three 0-Ethibond sutures (Ethicon, Raritan, NJ) from the preperitoneal or peritoneal space. Propensity score matching was used to adjust for confounding variables. RESULTS: The authors identified 231 patients with a mean [standard deviation] age of 46.7 [9.7] years and a mean BMI of 25.9 [4.4] kg/m2. Nine (3.9%) had diabetes, 8 (3.5%) were active smokers, and the median number of previous pregnancies was 2. In total, 223 (96%) had a traditional abdominoplasty, whereas 8 (3.5%) underwent a fleur-de-lys approach. Liposuction was performed on 90%, and 45.4% underwent simultaneous breast or body contouring surgery. The overall complication rate was 6.9%. Propensity scores matched 61 pairs in each group (n = 122) with closely aligned covariates. There was no significant difference in total complication rates between abdominoplasty alone vs abdominoplasty with hernia repair. There were no cases of skin necrosis or umbilical necrosis in either group. CONCLUSIONS: Performing umbilical hernia repair with abdominoplasty is safe when utilizing the technique reported in this series.
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Abdominoplastia , Hernia Umbilical , Humanos , Niño , Hernia Umbilical/cirugía , Puntaje de Propensión , Estudios de Cohortes , Estudios Retrospectivos , Abdominoplastia/efectos adversos , Abdominoplastia/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Necrosis/cirugíaRESUMEN
BACKGROUND: The prevalence of same-day mastectomy with reconstruction has continued to increase across the United States in recent years. Prior studies have shown that same-day mastectomy with reconstruction leads to increased patient satisfaction and allows hospitals to use resources better. This study sought to evaluate the implementation of same-day mastectomy with a reconstruction recovery protocol for patients undergoing mastectomy at our institution. METHODS: Under an institutional review board-approved protocol, a retrospective cohort analysis compared patients who underwent mastectomy April 2016 through April 2017 with those who had mastectomy March 2020 through March 2021. Length of stay, postoperative intravenous (IV) opioid administration, safety end points, and cost were the main variables examined. RESULTS: The study compared 457 patients in 2016-2017 with 428 patients in 2020-2021. The median hospital length of stay decreased from 24.6 h in 2016-2017 to 5.5 h in 2020-2021 (p < 0.001). The percentage of patients requiring postoperative IV opioids decreased from 69.1 % in 2016-2017 to 50 % in 2020-2021 (p < 0.001). The rates of unplanned readmissions within 30 days after mastectomy did not differ between the two groups, with a rate of 3.7 % in 2016-2017 and a rate of 5.1 % in 2020-2021 (p = 0.30). Reducing the rate of overnight admissions after mastectomy by 65.8 % resulted in a cost reduction of 65.8 %. CONCLUSIONS: Implementation of same-day mastectomy with a reconstruction protocol across a large academic center and two satellite sites was a safe alternative to conventional mastectomy recovery plans.
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Neoplasias de la Mama , Mamoplastia , Analgésicos Opioides , Neoplasias de la Mama/cirugía , Femenino , Humanos , Tiempo de Internación , Mamoplastia/métodos , Mastectomía/métodos , Estudios RetrospectivosRESUMEN
BACKGROUND: Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. METHODS: Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed. RESULTS: Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. CONCLUSIONS: Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.
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Neoplasias de la Mama , Mamoplastia , Mastectomía Subcutánea , Neoplasias de la Mama/cirugía , Femenino , Humanos , Mastectomía , Pezones/cirugía , Satisfacción del Paciente , Estudios RetrospectivosRESUMEN
OBJECTIVES: This study evaluates complications and reconstructive failure rates in implant-based reconstruction with radiotherapy. BACKGROUND: Postmastectomy radiotherapy may adversely affect breast reconstructive outcomes. However, the comparative effect of radiotherapy on direct-to-implant versus tissue expander-implant reconstruction has not been examined. METHODS: Single institution retrospective review was performed and patients were followed 2 to 10âyears. RESULTS: Of 1566 patients, 265 patients received radiation (149 immediate implants and 116 tissue expanders). Demographics were similar except more smokers in the expander group (7.7% vs 1.3%; P = 0.012). Patients who received radiation with an expander in place had overall more complications (32.8% vs 11.4%; P < 0.001), skin necrosis (10.3% vs 4.0%; P = 0.043), wound breakdown (9.5% vs 2.7%; P = 0.029), and infections (16.4% vs 4.03%; P = 0.001) leading to a higher rate of explantation (16.4% vs 4.0%; P < 0.001). A radiation boost likewise predicted complications [odds ratio (OR) 2.199, 95% confidence interval (CI) 1.154-4.188, P = 0.017]. When comparing reconstructive outcomes, radiated expanders had a higher failure rate (21.6% vs 11.4%; P = 0.025). Revision for capsular contracture was similar between the 2 cohorts (11.4% vs 11.2%; P = 0.959) as were revision rates for contour asymmetry and breast asymmetry. In our multivariable logistic regression analysis, radiation to the expander had a higher risk of reconstruction failure than radiation to the permanent implant (OR 2.020, 95% CI 1.010-4.037, P = 0.047). CONCLUSION: Most patients had successful implant-based reconstructions after mastectomy and radiotherapy. Our study showed radiotherapy after direct-to-implant breast reconstruction had a lower rate of complications and reconstructive failure compared to tissue expander-implant reconstruction.
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Implantes de Mama , Neoplasias de la Mama/radioterapia , Mamoplastia/métodos , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/cirugía , Femenino , Humanos , Mastectomía , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Dispositivos de Expansión TisularRESUMEN
Implant-based breast reconstruction is the most common means to rebuild the breast following mastectomy. Although largely successful in restoring breast shape, suboptimal results may occur secondary to inadequate size or projection, malposition, rippling and contour irregularities, nipple malposition, capsular contracture, or implant rotation/flipping. This article reviews common strategies to improve implant reconstruction outcomes with revisional surgery.
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Implantación de Mama , Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Implantación de Mama/efectos adversos , Implantes de Mama/efectos adversos , Humanos , Mamoplastia/efectos adversos , Mastectomía , Estudios RetrospectivosRESUMEN
INTRODUCTION: Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in surgery. METHODS: A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge [median oral morphine equivalent (OME)] were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied. RESULTS: A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative. CONCLUSION: We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.
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Analgésicos Opioides/efectos adversos , Prescripción Inadecuada/prevención & control , Comunicación Interdisciplinaria , Trastornos Relacionados con Opioides/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Adulto , Analgésicos Opioides/uso terapéutico , Prescripciones de Medicamentos/estadística & datos numéricos , Revisión de la Utilización de Medicamentos , Femenino , Humanos , Relaciones Interprofesionales , Masculino , Persona de Mediana Edad , Evaluación de Necesidades , Trastornos Relacionados con Opioides/epidemiología , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Cooperación del Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/tendencias , Estadísticas no Paramétricas , Estados UnidosAsunto(s)
Neoplasias de la Mama , Pezones , Humanos , Pezones/cirugía , Pezones/patología , Femenino , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/patología , Márgenes de Escisión , Mastectomía/métodos , Tratamientos Conservadores del Órgano/métodos , Pronóstico , Mastectomía Subcutánea/métodosRESUMEN
OBJECTIVE: We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone. BACKGROUND: Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema. METHODS: A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months' median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors. RESULTS: Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59-6.41%] implant, 9.89% (95% CI: 4.98-19.1%) autologous, and 26.7% (95% CI: 20.4-34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, Pâ<â0.0001] but not autologous (HR: 0.706, Pâ=â0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (Pâ<â0.0001), higher body mass index (Pâ<â0.0001), and greater number of nodes dissected (Pâ=â0.0324) were associated with increased lymphedema risk. CONCLUSIONS: This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.
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Implantación de Mama , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Linfedema/prevención & control , Mastectomía , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Estimación de Kaplan-Meier , Linfedema/epidemiología , Linfedema/etiología , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: The last decade has seen an increasing prevalence of prophylactic mastectomies with decreasing age of patients treated for breast cancer. Data are limited on the prevalence of histopathologic abnormalities in this population. This study aimed to measure the prevalence of histopathologic findings in contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) patients and identify predictors of findings. METHODS: Our institution's prophylactic mastectomies from 2004 to 2011 were reviewed. Breast specimens with prior malignancies were excluded. Patient factors and pathology reports were collected. Independent predictive factors were identified with univariate and multivariate logistic analysis. RESULTS: A total of 524 specimens in 454 patients were identified. Malignancy was found in 7.0% of CPM and 5.7% of BPM specimens. In CPM patients, ipsilateral lobular carcinoma-in situ [odds ratio (OR) 4.0] and mammogram risk group (OR 2.0) were predictive of malignancy. Age group (OR 1.5), ipsilateral lobular carcinoma-in situ (OR 2.3), and prior bilateral salpingo-oophorectomy (OR 0.3) were predictive of moderate- to high-risk histopathology. Only increasing age group was predictive of increased moderate- to high-risk histopathology in BPM patients (OR 2.3). There were no independent predictors of malignancy in BPM. BRCA status was not predictive in either CPM or BPM. CONCLUSIONS: Patients with lobular carcinoma-in situ in the index breast or high-risk mammograms have a higher prevalence of malignancies. Although BRCA patients may benefit from prophylactic mastectomy, the genetic diagnosis does not increase the prevalence of detecting occult pathology. BPM patients can be counseled about relative risk, where occult pathology increases with age.
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Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/patología , Carcinoma Lobular/patología , Mastectomía , Adulto , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Carcinoma Lobular/cirugía , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Invasividad Neoplásica , Estadificación de Neoplasias , Pronóstico , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: Nipple-sparing mastectomies (NSM) are increasingly common because of their cosmetic advantage. Radiotherapy (RT) has been a relative contraindication to immediate reconstruction because of concerns about increased complications. We aimed to evaluate outcomes of NSM plus immediate reconstruction in irradiated breasts and to determine additional risk factors for complications. METHODS: We retrospectively reviewed NSM with immediate reconstruction from 2007 to 2013 at our institution. Complications were broken down into several categories. Potential risk factors for complications were evaluated. RESULTS: There were 982 NSM: 816 had no RT, 67 had prior RT, and 97 had postmastectomy radiotherapy (PMRT). Compared to breasts with no RT, both prior RT and PMRT increased overall complications (10.2 vs. 21.7 and 17.5%, p = 0.003, 0.03, respectively) and nipple loss (0.9 vs. 4.3 and 4.1%, p = 0.04, 0.02, respectively), while PMRT increased rate of reconstruction failure (2.2 vs. 8.2%, p = 0.003). On multivariate regression analysis, prior RT [odds ratio (OR) 2.53, p = 0.006], PMRT (OR 2.29, p = 0.015), age >55 years (OR 2.03, p = 0.04), breast volume ≥800 cm(3) (OR 1.96, p = 0.04), smoking (OR 2.62, p = 0.001), and periareolar incision (OR 1.74, p = 0.03) were independent risk factors for complications requiring surgical revision. In irradiated breasts, complication rates were 13.4% without further risk factors and 17.5, 50, and 66.7% when 1, 2, and ≥3 additional independent risk factors were present, respectively (p < 0.001). CONCLUSIONS: Although complication rates were higher in irradiated breasts, reconstruction failure and nipple/areola necrosis was infrequent. RT should not be a contraindication to NSM. Preoperative identification of risk factors and appropriate patient selection may reduce complication rates.
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Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Mamoplastia , Mastectomía , Pezones/cirugía , Tratamientos Conservadores del Órgano , Selección de Paciente , Complicaciones Posoperatorias , Adulto , Anciano , Neoplasias de la Mama/patología , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Radioterapia Adyuvante , Estudios Retrospectivos , Factores de Riesgo , Colgajos Quirúrgicos , Adulto JovenRESUMEN
Increased bilateral mastectomy for breast cancer treatment has generated an increased demand for bilateral breast reconstruction. This study examines changing patterns of reconstruction over the last decade to accommodate increased case volume and decreased morbidity associated with reconstruction. A single institution series of 3171 consecutive breast reconstruction cases of more than 10 years was divided into 2 periods, that is, 1999 to 2004 and 2005 to 2010. Bilateral breast reconstruction case volume increased 260% from 1999 to 2004 (n = 237) to 2005 to 2010 (n = 634). Mean patient age at diagnosis decreased by 7 years (P < 0.001). In 2005 to 2010, autologous reconstruction decreased from 60% to 26%, implant-based reconstruction increased from 40% to 74%. There was a noted increase in single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (P < 0.001). Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%) in the later period. A younger patient demographic and increased case volume were accommodated through increased single-staged and prosthesis-based procedures.
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Neoplasias de la Mama/cirugía , Costos de Hospital/estadística & datos numéricos , Mamoplastia/métodos , Adulto , Anciano , Implantación de Mama/economía , Implantación de Mama/estadística & datos numéricos , Implantación de Mama/tendencias , Neoplasias de la Mama/economía , Femenino , Estudios de Seguimiento , Costos de Hospital/tendencias , Humanos , Mamoplastia/economía , Mamoplastia/estadística & datos numéricos , Mamoplastia/tendencias , Mastectomía/economía , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Reoperación/economía , Reoperación/estadística & datos numéricos , Reoperación/tendencias , Estudios Retrospectivos , Colgajos Quirúrgicos/economía , Colgajos Quirúrgicos/estadística & datos numéricos , Colgajos Quirúrgicos/tendencias , Expansión de Tejido/economía , Expansión de Tejido/estadística & datos numéricos , Expansión de Tejido/tendencias , Resultado del TratamientoRESUMEN
BACKGROUND: Prosthetic reconstruction of the breast, as a 2-staged procedure using tissue expanders followed by placement of permanent implants, offers favorable aesthetic results with minimal additional surgical intervention. However, the current outpatient process to fill saline expanders can be lengthy and onerous, involving months of office visits and discomfort from the bolus saline expansions. We present a new technology (AeroForm Tissue Expansion System), which has the potential to improve the process of breast tissue expansion by providing a method for low-volume incremental filling, eliminating the need for injections and directly involving the patient by allowing her some control over the expansion process. METHODS: The described study is a 2:1 randomized controlled trial of the investigational CO2 expansion system and saline expanders. Of the 82 women receiving expanders, 58 (39 bilateral and 19 unilateral; bilateral rate, 67%) were implanted with CO2 tissue expanders and 24 subjects (15 bilateral and 9 unilateral; bilateral rate, 63%) were implanted with saline expanders. RESULTS: Preliminary validated expansion results were available for 55 women. Available mean time for active expansion in the CO2 group was 18.2 (9.2) days (median, 14.0; range, 5-39; number of expanders, 53), which was less than the mean time for active expansion in the saline group: 57.4 (33.6) days (median, 55; range, 5-137; number of expanders, 33). Available mean time from implant placement to exchange for a permanent prosthesis in the CO2 group was shorter [106.3 (42.9) days; median, 99; range, 42-237; number of expanders, 53] than for the women in the control group [151.7 (62.6) days; median, 140; range, 69-433; number of expanders, 33]. After 2 events--underexpansion (n=1) and erosion (n=1)--in the CO2 group, the internal membrane was redesigned and the expander bulk was decreased to minimize the risk of underexpansion and erosion in subsequent patients. CONCLUSIONS: Preliminary evidence indicates that the CO2-based tissue expansion system performs the same function as saline expansion devices without significantly altering the risk to the patient and that the device has the potential to make the expansion process faster and more convenient for both the patient and the physician.
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Implantación de Mama/métodos , Dispositivos de Expansión Tisular , Expansión de Tejido/instrumentación , Adolescente , Adulto , Anciano , Implantes de Mama , Dióxido de Carbono , Femenino , Humanos , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Cloruro de Sodio , Expansión de Tejido/métodos , Adulto JovenRESUMEN
SUMMARY: Aesthetic surgery is a visual specialty in which plastic surgeons and patients work together to enhance or restore facial and body harmony. The field of aesthetic surgery is advanced through descriptive technical procedures and outcomes research. With increasing competition in cosmetic medicine, aesthetic surgery stands to benefit from an evidence-based approach to document the high standards of care from board-certified plastic surgeons. In this article, the authors highlight challenges, current objective and subjective outcomes, and a path forward.
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Cirujanos , Cirugía Plástica , Humanos , Certificación , Estética , Cara/cirugíaRESUMEN
The p-value is ubiquitous in research. However, misuse and misinterpretation are common. This special topics article aims to demystify the p-value for researchers, students, physicians, and experienced investigators alike. To accomplish this aim, the origins of the p-value, what they represent, and principles of application are described through use of examples from real datasets. Developing understanding of the true meaning of this statistical measure has the power to improve and inform clinical research.
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BACKGROUND: Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. The authors present one of the largest breast reconstruction series in the literature. METHODS: A single-institution retrospective review was conducted from 2007 to 2019. RESULTS: The authors' query identified 3035 implant-based breast reconstructions after nipple-sparing mastectomy, including 2043 direct-to-implant and 992 tissue expander-to-implant reconstructions. The overall major complication rate was 9.15%, and the nipple necrosis rate was 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared with prophylactic mastectomy ( P < 0.01). In comparisons of unilateral and bilateral procedures, bilateral mastectomy had an increased risk for complications (OR, 1.46; 95% CI, 0.997 to 2.145; P = 0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% versus 0.88%; P = 0.015), infection (4.2% versus 2.8%; P = 0.04), and explantation (5.1% versus 3.5%; P = 0.04) compared with direct-to-implant reconstruction. When assessing plane of reconstruction, the authors found similar rates of complications between subpectoral dual-plane and prepectoral reconstruction. There was no difference in complications between reconstruction with acellular dermal matrix or mesh compared with total or partial muscle coverage without acellular dermal matrix/mesh (OR, 0.749; 95% CI, 0.404 to 1.391; P = 0.361). Multivariable regression analysis revealed preoperative radiotherapy (OR, 2.465; 95% CI, 1.579 to 3.848; P < 0.001), smoking (OR, 2.53; 95% CI, 1.581 to 4.054; P < 0.001), and a periareolar incision (OR, 3.657; 95% CI, 2.276 to 5.875; P < 0.001) to be the strongest predictors of complications and nipple necrosis ( P < 0.05). CONCLUSIONS: Nipple-sparing mastectomy and immediate breast reconstruction has a low rate of complications. In this series, radiation therapy, smoking, and incision choice predicted overall complications and nipple necrosis, whereas direct-to-implant reconstruction and acellular dermal matrix or mesh did not increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Asunto(s)
Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Humanos , Femenino , Mastectomía/efectos adversos , Neoplasias de la Mama/etiología , Pezones/cirugía , Mamoplastia/efectos adversos , Mamoplastia/métodos , Estudios Retrospectivos , Necrosis/epidemiología , Necrosis/etiología , Necrosis/cirugíaRESUMEN
BACKGROUND: Eligibility for nipple-sparing mastectomy (NSM) varies widely on the basis of patient and tumor factors. METHODS: Review of patients undergoing NSM from June 2007 to December 2012 at our institution was performed. Patient and tumor characteristics, complications, and recurrences were collected. NSM from 2007 to 2010 and 2011 to 2012 were compared to assess trends in eligibility and outcomes over time. RESULTS: NSM was performed on 645 breasts in 370 patients. Indications were risk reduction in 330 (51.2 %), invasive cancer in 226 (35.0 %), and ductal carcinoma-in situ in 89 (13.8 %) breasts. Fifty-one (13.8 %) patients had positive lymph nodes. Twenty-seven (7.3 %) patients received neoadjuvant chemotherapy. Forty-eight (7.4 %) breasts had prior radiotherapy. Total nipple necrosis occurred in 11 (1.7 %) breasts. Twenty-four (3.7 %) breasts had nipples removed as a result of positive subareolar/nipple margins. At 22 months' mean follow-up, local recurrence occurred in 4 of 156 (2.6 %) breasts operated on for cancer through 2011. No recurrences involved the nipple. NSM performed in 2011-2012 (n = 475) compared to 2007-2010 (n = 170), were more often for cancer, in patients with higher body mass index, and on larger breasts (p < 0.001). There was no significant difference in total nipple necrosis rates between groups. Nipple loss due to positive subareolar/nipple margins was significantly less in 2011-2012 (p = 0.027). CONCLUSIONS: Eligibility for NSM has expanded to include women with higher body mass index and larger breasts, with no increase in nipple loss due to ischemia. Rates of positive subareolar margins have decreased over time, even though NSM is being performed more frequently for cancer, suggesting improved patient selection.
Asunto(s)
Neoplasias de la Mama/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Mastectomía , Recurrencia Local de Neoplasia/cirugía , Pezones/cirugía , Selección de Paciente , Adulto , Anciano , Neoplasias de la Mama/patología , Carcinoma Intraductal no Infiltrante/patología , Femenino , Estudios de Seguimiento , Humanos , Mamoplastia , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Pezones/patología , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Colgajos Quirúrgicos , Adulto JovenRESUMEN
SUMMARY: Circumferential body contouring addresses abdominal, mons, lateral thigh, and buttock laxity. The goals of contouring are to optimize abdominal aesthetics while also addressing lateral thigh and buttock skin excess with an easily concealed scar. Key concepts in contemporary lower lift include a low anterior scar that gently slopes superior to help with waist accentuation and addressing lateral thigh contour. The posterior scar lies at the top of the gluteal crease to preserve the buttocks aesthetic unit, allow for autoaugmentation, and minimize wound-healing complications. Patient safety considerations include thromboembolism prevention, minimizing blood loss, and keeping the patient warm. With proper planning, the lower body lift effectively and aesthetically removes circumferential skin laxity.