Analysis of flap thickness to breast projection ratio correlating to body mass index and age in east Asian women: Considerations in flap selection in breast reconstruction.

BACKGROUND: Several alternative flaps have been introduced and used for autologous breast reconstruction. However, as body fat distribution is different among patients, the donor of choice for sufficient breast projection varies between patients. METHODS: Patients who underwent autologous breast reconstruction from Jan 2018 to Sep 2022 were included. Age, body mass index (BMI), smoking history and hypertension, and diabetes occurrence were collected as baseline demographic data. Breast projection with five types of flap thickness was measured based on computed tomography angiography. Analysis was performed for five major autologous flaps for breast reconstruction. RESULTS: A total of 563 patients were included in the study. The mean age of the patients was 47.4 ± 7.9 (standard deviation; SD) years. The mean BMI of the patients was 24.0 ± 3.4 kg/m2. Only the correlation between flap thickness to breast projection ratio and age in the PAP flap illustrated statistical significance (p = .039), but the correlation coefficient was quite low (r = -0.087). Slim patients who had lower BMIs (under 25 kg/m2) had significantly higher sufficient flap thickness for breast reconstruction than patients with higher BMIs over 25 kg/m2 in the profunda artery perforator (PAP) flap (p < .001), the lumbar artery perforator (LAP) flap (p < .001), and the superior gluteal artery perforator (SGAP) flap (p < .001). CONCLUSIONS: The deep inferior epigastric perforator flap provided sufficient thickness and was not usually affected by age and BMI. The PAP, LAP, and SGAP flaps tended to maintain the thickness of the flap even when BMI decreased, so they are advantageous for reconstruction in slim patients. This study contributes evidence in consideration of flap selection in autologous breast reconstruction.

Human-Mimic Submuscular and Premuscular Irradiated Rat Model: Histologic Characteristics of the Capsule Tissue in Contact with the Breast Implant.

Background: In this study, we established two rat models that mimic human submuscular and premuscular breast reconstruction. We analyzed the capsule formation according to surgical techniques and adjacent tissues, including the chest wall tissues, such as the ribs and acellular dermal matrices (ADMs) that come in contact with silicone implants. Methods: This study consisted of experiments on 12 Sprague-Dawley rats that underwent implant reconstruction using ADM. They were divided into two groups: rats that underwent dual-plane implantation (n = 6; group 1) and those that underwent premuscular implant insertion (n = 6; group 2). All rats were irradiated with 35 Gy of fractionated radiation. Three months after surgery, the histology and immunochemistry of the capsule tissues of the ADM, muscle, and chest wall were analyzed. Results: Overall capsule thickness was thicker in group 1. Based on the tissue in contact with the silicone implant, ADM had a thinner capsule, less inflammation, less fibrosis, and less vascularization than the muscle and chest wall tissues. Conclusions: This study described two rat models of clinically relevant implant-based breast reconstruction using a submuscular and premuscular plane, ADM, and irradiation. Overall, the premuscular implantation rat model was associated with a thinner capsule. The ADM in contact with the silicone implant, even after irradiation, had superior protection from radiation compared with the other tissues.

Safety of Augmenting Breast Volume in Direct-to-Implant Breast Reconstruction With Contralateral Breast Augmentation: Comparison With 2-Stage Reconstruction.

BACKGROUND: Direct-to-implant breast reconstruction is a standard method of implant-based reconstruction; however, the risk of skin necrosis and implant failure exists. During simultaneous contralateral augmentation, an implant larger than the resected tissue must be inserted to balance both sides, which may increase the risk of complications. This study examined the differences in the incidence of complications between the single-stage direct-to-implant reconstruction and 2-stage reconstruction when contralateral augmentation was performed simultaneously. METHODS: This study included 99 patients who underwent implant-based breast reconstruction with contralateral augmentation between 2012 and 2020. A retrospective chart review was conducted and the patients were divided into 2 groups: the single-stage reconstruction (n = 61) and 2-stage reconstruction (TSR, n = 38) groups. Demographic data and surgical and oncological information were collected. Complications including skin necrosis and reconstruction failure were investigated as the primary outcome. RESULTS: Implant volume and contralateral implant volume were significantly greater in TSR group than in the single-stage reconstruction group. There were no significant differences in the incidence of complications and reconstruction failure rates between both groups. The nipple-sparing mastectomy was the risk factor for complications. Furthermore, the risk factors for mastectomy skin necrosis were implant volume and differences in the volume of both implants. CONCLUSIONS: Single-stage reconstruction did not increase the risk of complications compared with TSR when implants that were larger than the resected tissue were inserted after mastectomy. Proper patient selection and selection of implants that are not excessively large could satisfy patients' cosmetic needs in a single operation.

Comparative Study of DIEP and PAP Flaps in Breast Reconstruction: Reconstructive Outcomes and Fat Necrosis.

BACKGROUND: This study compared the reconstructive outcomes and fat necrosis of the profunda artery perforator (PAP) flap with those of the deep inferior epigastric perforator (DIEP) flap. METHODS: Data on all DIEP and PAP flap breast reconstructions performed between 2018 and 2021 at Asan Medical Center were compared. The overall reconstructive outcomes and presence of fat necrosis were analyzed through ultrasound evaluation performed by a board-certified radiologist. RESULTS: The PAP (n = 43) and DIEP flaps (n = 99) were used to reconstruct 31 and 99 breasts, respectively. The average age of the patients in the PAP flap group (39.1 ± 7.3 years) was lower than in the DIEP flap group (47.4 ± 7.7 years), and the body mass index (BMI) of patients undergoing PAP flap reconstruction (22.7 ± 2.8 kg/m2) was lower than those undergoing DIEP flap reconstruction (24.3 ± 3.4 kg/m2). There was no total loss of both flaps. Donor site morbidity was higher in the PAP flap group (11.1%) compared with the DIEP flap (1.0%). The rate of fat necrosis was higher in the PAP flaps (40.7%) than in the DIEP flaps (17.8%) during ultrasound. CONCLUSION: In our study, we found that PAP flap reconstruction tended to be performed in patients who were younger with lower BMIs compared with the DIEP flap. Successful reconstructive outcomes were observed in both the PAP and DIEP flaps; however, a higher rate of necrosis was observed in the PAP flap compared with the DIEP flap.

Cadaveric Study for Safe Elevation of a Profunda Artery Perforator Flap: Anatomy of the Perforators and Obturator Nerves.

BACKGROUND: This cadaveric study aimed to describe the anatomy of the profunda artery perforators (PAPs). METHODS: In total, nine free cadavers with 18 upper thighs were dissected, 12 of which were from female cadavers, and 6 were from male cadavers. The average age of the cadavers was 84.7 ± 4.2 years. Dissection was performed to evaluate the anatomic position and characteristics of the femoral PAPs. The perforator distance from the gluteal sulcus, number of perforators, perforating muscles, diameter of the perforators, origin of the perforators, and number of nerves passing above and below the perforators were determined. RESULTS: The average number of perforators that penetrate the adductor magnus muscle was 2.5. The average distance from the origin of the perforators to the gluteal sulcus was 71.72 ± 28.23 mm. The average numbers of the obturator nerves passing above and below the perforator in the adductor magnus muscle were 1.3 (range, 0-4) and 0.7 (range, 0-2), respectively. CONCLUSION: The results provide a detailed anatomic basis for the PAP flap. The perforators of a PAP flap may be included in a flap with a transverse design. Sacrificing the small obturator nerves during dissection may not lead to significant donor site morbidity.

A Propensity Score-matched Analysis of Long-term Oncologic Outcomes After Nipple-sparing Versus Conventional Mastectomy for Locally Advanced Breast Cancer.

OBJECTIVES: To compare the long-term oncologic outcomes of nipple-sparing mastectomy (NSM) with those of conventional mastectomy (CM) in patients with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy (NACT). SUMMARY OF BACKGROUND DATA: NSM has been increasingly implemented in patients with breast cancer. However, oncologic efficacy of NSM in patients with LABC has not been sufficiently demonstrated. METHODS: The study group comprised 850 patients with clinical stage IIB to IIIC breast cancer who underwent NACT followed by either NSM and immediate breast reconstruction or CM alone. After propensity score-matching, 418 patients were included in the analysis. Local recurrence-free survival, disease-free survival (DFS), distant metastasis-free survival, and overall survival (OS) rates were calculated using the Kaplan-Meier method and compared using log-rank tests between the NSM and CM groups. RESULTS: After matching, the mean follow-up period was 70 ± 25 months for the NSM group and 74 ± 27 months for the CM group ( P = 0.181). There were no significant differences between the groups in terms of 6-year local recurrence-free survival (91.6% vs. 95.8%; P = 0.239), DFS (70.5% vs. 73.4%; P = 0.583), distant metastasis-free survival (79.8% vs. 77.4%; P = 0.320), or OS (87.6% vs. 84.8%; P = 0.465) rates. Additionally, we identified 30 patients in the NSM group who initially presented with tumor extension in the subareolar area; the nipple-areola complex was successfully preserved after NACT, and no recurrence at the nipple was observed in these patients. CONCLUSIONS: In this matched control study, we demonstrated comparable long-term oncologic outcomes between NSM with immediate reconstruction and CM alone after NACT for LABC. In patients who had tumors extending to the subareolar area before NACT, NSM can be tried if tumor involvement of the nipple-areola complex appears resolved on imaging studies after chemotherapy.

Breast cancer outcomes following immediate breast reconstruction with implants versus autologous flaps: a propensity score-matched study.

PURPOSE: A large proportion of patients with breast cancer who had mastectomy had undergone breast reconstruction with implants or autologous flaps. However, only a few studies have compared the breast cancer outcomes between the implant-based reconstruction (IBR) and autologous flap reconstruction (AFR). In this study, we retrospectively compared the local recurrence rates, distant metastasis rates, and survival outcomes between immediate IBR and AFR. METHODS: A total of 1530 patients with primary breast cancer who underwent IBR or AFR with nipple-/skin-sparing mastectomy were included. Patients who underwent neoadjuvant systemic therapy were excluded from the study. After propensity score matching by age at diagnosis, T stage, N stage, molecular subtype, mastectomy type, adjuvant radiotherapy status, and follow-up period, 938 patients were 1:1 matched, comprising the well-balanced IBR and AFR groups. Locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and breast cancer-specific survival (BCSS) were compared between the matched groups. RESULTS: After matching, the median follow-up periods were 68 months and 71 months for the IBR and AFR groups, respectively. No significant differences were observed between the IBR and AFR groups regarding the local recurrence (7.2% vs. 5.1%; P = 0.175), regional recurrence (2.1% vs. 1.5%; P = 0.463), or distant metastasis (3.2% vs. 3.2%; P = 1.000) rates. Moreover, no significant difference was observed between the IBR and AFR groups in the LRRFS (hazard ratio, 0.691; 95% CI, 0.433-1.102; P = 0.118), DFS (hazard ratio, 0.709; 95% CI, 0.468-1.076; P = 0.104), DMFS (hazard ratio, 1.006; 95% CI, 0.491-2.059; P = 0.987), or BCSS (hazard ratio, 0.445; 95% CI, 0.111-1.786; P = 0.659). CONCLUSION: In this propensity score-matched analysis of oncologic outcomes in patients with primary breast cancer who underwent immediate breast reconstruction with nipple-/skin-sparing mastectomy, no significant differences were observed between the IBR and AFR groups.

Outcome Analysis Depending on the Different Types of Incision following Immediate Breast Reconstruction.

Background: Immediate breast reconstruction following nipple-sparing mastectomy (NSM) is widely used for its cosmetic benefits. Due to the lack of guidelines, the types of incisions in NSM vary and which method is superior remains a debate. In this study, we hypothesized that the periareolar incision has a higher risk of complications, such as nipple-areolar complex (NAC) necrosis, than other incisions. Methods: A retrospective chart review was conducted and divided into three groups: the periareolar, radial, and lateral incision groups. The reconstruction method and complications of NAC necrosis, wound dehiscence, seroma, hematoma, infection, and reconstruction failure were investigated. Results: A total of 103 patients (periareolar incision (33%, n = 34), radial incision (39.8%, n = 41), and lateral incision (27.2%, n = 28)) who underwent NSM and immediate breast reconstruction from 2018 to 2020 were included. The reconstruction methods were direct-to-implant, DIEP flap, LD flap, and PAP flap, and there was all of which had no statistically significant difference between the groups regarding the reconstruction method (p=0.257). In terms of complications, there was no significant difference in NAC necrosis (29.4%, 19.5%, and 21.4%, in the periareolar, radial, and lateral groups, respectively; p=0.578), wound dehiscence, seroma or hematoma, infection, and reconstruction failure. Conclusion: Breast reconstruction following NSM through periareolar incision does not increase the incidence of complications, including NAC necrosis. However, since only Asian patients with low BMI were included, if an appropriate patient group is selected for immediate reconstruction after NSM, reconstruction can be safely performed through the periareolar incision, and good cosmetic results can be obtained.

Is There a Difference in the Diagnosis and Prognosis of Local Recurrence between Autologous Tissue and Implant-Based Breast Reconstruction?

Introduction: Breast reconstruction has become common after total mastectomy; however, certain types of breast reconstruction may be associated with delayed local recurrence or poor survival. Here, we investigated whether there are differences in the diagnosis and prognosis of local recurrence between autologous reconstruction and implant reconstruction. Materials and Methods: A retrospective analysis was performed on patients undergoing breast cancer surgery with autologous tissue or immediate implant reconstruction in a single center (January 2003-December 2017). Patient data including the period from cancer surgery to local recurrence diagnosis, tumor size at the time of recurrence, and survival time after cancer surgery and recurrence detection were analyzed. Results: There was a significant difference (p = 0.021) in the time from surgery to recurrence between the autologous tissue (1,246 days) and implant (909 days) groups. Recurrence tumor size did not differ (autologous: 1.00 cm2 vs. implant: 0.90 cm2; p = 0.813). Survival time after surgery (p = 0.63) and recurrence detection (p = 0.74) did not statistically significant. Conclusions: Statistical difference in the detection time was observed between autologous tissue and implant group. On the other hand, there is no difference in recurrence tumor size or survival time. A further study is necessary to identify the different detection time of local recurrence.

Revision Rates of Left and Right Breast Reconstruction Differ With DIEP Flaps: Implications for Inexperienced Surgeons.

BACKGROUND: The internal mammary system provides the recipient vessel of choice in free autologous tissue breast reconstruction. However, left internal mammary veins (IMVs) are smaller than right IMVs, thus raising questions about their reliability. Here we analyzed right and left breast deep inferior epigastric perforator (DIEP) flap reconstruction performed by an experienced versus less experienced surgeon and hypothesized that less experienced surgeons might encounter difficulty in cases of smaller left IMVs. METHODS: We respectively reviewed the charts of 714 DIEP flap breast reconstructions performed by an experienced surgeon (>15 years' DIEP flap experience) and 231 performed by a relatively inexperienced surgeon (<4 years' DIEP flap experience). Reconstructions requiring microvascular revisions were compared with nonrevision controls, and left-side reconstructions were compared with right-side controls. RESULTS: Preoperative risk factors were not significantly different between the left and right cohorts for either surgeon. The experienced surgeon performed 17 microvascular revisions (2.4%), including 9 left (52.9%) and 8 right (47.1%). The less experienced surgeon performed 7 microvascular revisions (3.0%), all left. The left- and right-side revision rates were 2.4% and 2.3% for the experienced surgeon versus 6.1% and 0% for the less experienced surgeon, respectively, with a higher rate for the left side (P = 0.0299). CONCLUSIONS: The left-side microvascular revision rate was higher for the less experienced surgeon. Considering that left IMVs are smaller, less experienced surgeons should carefully perform left-side free flap breast reconstructions and be prepared to convert to thoracodorsal recipient vessel use.

Seasonal and Temperature-associated Effect on Infection in Implant-based Breast Reconstruction.

BACKGROUND AND OBJECTIVES: Despite advances in medicine, infection at the surgical site is an impregnation problem that most surgeons confront. Although studies on the seasonality of infection have been conducted in various areas, no study has confirmed the relationship between seasonal temperature and infection after breast reconstruction. METHODS: From 2008 to 2018, a retrospective study was conducted on patients who underwent implant-based breast reconstruction. Patient demographics, intraoperative data, postoperative data, and temperature information were collected. Temperature differences between cases with and without infection were examined. The differences in the incidence and risk of infection by season were estimated according to the hot season (July to August) and the nonhot season (September to June). RESULTS: Of the 460 cases enrolled, 42 cases developed an infection. Among them, 15 (35.71%) cases developed infection during the hot season (P = 0.003). According to the logistic regression model, the risk of infection was 2.639 times higher in the hot season than in the nonhot season (95% confidence interval, 1.282-5.434; P = 0.008). When the temperature was higher than 25°C, the risk of infection increased by 45.2% for every 1°C increase, which was statistically significant (odds ratio, 1.452; 95% confidence interval, 1.198-1.76; P < 0.001). CONCLUSION: In conclusion, the hot season or average temperatures higher than 25°C increase the risk of infection in patients undergoing implant-based breast reconstruction. It is essential to focus on skin hygiene during the healing of the incision site.

The Influence of Flow Velocity in the Feeding Vessel on Flap Perfusion in Deep Inferior Epigastric Artery Perforator Flap.

BACKGROUND: Contralateral perfusion of zones II and IV is critical to estimate the amount of fat necrosis and determine intraoperative flap sacrifice during autologous breast reconstruction. We aimed to determine whether perfusion of the contralateral side was affected by the peak flow velocity in the feeding vessels in the deep inferior epigastric artery (DIEA) perforator free flap reconstructions. METHODS: This was a retrospective review of patients who received DIEA perforator flap for autologous breast reconstruction from February to July 2020. Intraoperative indocyanine green (ICG) angiography and measurement software (Image J) were used to validate the perfusion of the contralateral side of the flap. Peak flow in the vessels was measured with duplex color Doppler and linear correlation was used to analyze the association between perfusion and blood flow velocity. RESULTS: Forty-two patients received a DIEP flap. The average age of the patients was 48.5 years, and body mass index was 23.84 kg/m2. Peak flow velocity of the internal mammary artery (IMA) was significantly higher than that of the DIEA (p <0.05). Contralateral perfusion confirmed by ICG angiography was higher in the IMA than in the DIEA (p <0.05). A linear correlation was found between peak speed (p = 0.045) and ICG perfusion length (p = 0.00003). CONCLUSION: The status of flap perfusion depends on the feeding vessel. The velocity of blood flow between IMA and DIEA is different, and the flap perfusion varies accordingly. Therefore, ICG angiography should be performed after anastomosis at the recipient site for an accurate assessment.

Intramuscular Deep Inferior Epigastric Vessels Are Insulated by Perimysial Fibroadipose Tissue Network.

BACKGROUND: The difficulty of elevating a deep inferior epigastric perforator (DIEP) flap largely depends on the intramuscular course of the vessel and the perforator. Previous studies, however, have lacked histologic descriptions of the vessels and surrounding structures. The present study analyzed the histologic aspects of the deep inferior epigastric vessels and perforators, focusing on their perivascular relationships with muscle fibers. METHODS: The abdomen of a cadaver was histologically evaluated to identify intramuscular deep inferior epigastric vessels. Tissue samples were stained with hematoxylin and eosin and with Masson trichrome stain to visualize fibrous components. Twenty-one DIEPs from 12 patients were also evaluated to determine the histologic aspects of the perivascular structure. In the cross-section of each perforator and adjacent tissue, the perforator-to-muscle distance and trichrome-stained area were measured, and the correlation of the perforator size with the perforator-to-muscle distance and the percent collagenous portion of the distance were determined. RESULTS: Histologic analysis showed that the deep inferior epigastric vessels and perforators were encased by perimysial connective tissue and were not in direct contact with the muscle fibers. The smaller perimysia branched out from the larger perimysia, forming an interconnecting network structure. Correlation analysis showed that larger vessels had more collagenous portions in the perimysial structures (Spearman's ρ = 0.537, p = 0.012). CONCLUSION: The deep inferior epigastric vessels and perforators reside in a perimysial fibroadipose tissue network. This may provide surgeons with a microscopic perspective during DIEP dissections. Having an idea of the perforator anatomy in microscopic level can help us to perform safer perforator dissections.

Oncologic Outcomes of Nipple-sparing Mastectomy and Immediate Reconstruction After Neoadjuvant Chemotherapy for Breast Cancer.

OBJECTIVES: To evaluate the oncologic outcomes and risk factors for locoregional recurrence (LRR) and nipple-areola complex recurrence (NR) in a large series of breast cancer patients who underwent nipple-sparing mastectomy (NSM) and immediate reconstruction after neoadjuvant chemotherapy (NACT). SUMMARY OF BACKGROUND DATA: The use of NSM and immediate reconstruction in breast cancer patients receiving NACT is increasing. However, the oncologic safety of this approach is unclear. PATIENTS AND METHODS: A total of 310 breast cancer patients (319 breasts) who underwent NACT and NSM between February 2010 and November 2016 were retrospectively analyzed. Clinical and pathologic factors associated with increased risks of LRR and NR were analyzed using univariate (Chi-square or Fisher exact test) and multivariate (Cox proportional hazard regression model) analyses. RESULTS: During a mean follow-up of 63 ± 22 months, 38 cases had LRR as the first event, including 6 cases of NR as the first event. The 5-year cumulative LRR and NR rates were 11.0% and 1.9%, respectively. In univariate analysis, clinical T stage, pathologic nodal status, histologic grade, lymphovascular invasion, and post-NACT Ki67 status were associated with increased LRR risk, and post-NACT Ki67 status was the only significant risk factor for NR. In multivariate analysis, post-NACT Ki67 ≥10% (hazard ratio, 4.245; 95% confidence interval, 1.865-9.663; P = 0.001) was an independent risk factor for LRR. CONCLUSIONS: NSM and immediate reconstruction seem to be oncologically safe with acceptable LRR and NR rates for appropriately selected breast cancer patients treated with NACT. Post-NACT Ki67 ≥10% was associated with increased risk of LRR or NR, and therefore, necessitates cautious follow-up.

A propensity score-matched comparison of recurrence outcomes after immediate implant vs autologous flap reconstruction in patients receiving neoadjuvant chemotherapy for breast cancer.

PURPOSE: We compared oncologic outcomes between breast cancer patients who underwent immediate implant-based breast reconstruction (IBBR) and those who underwent autologous flap reconstruction (AFR) after neoadjuvant chemotherapy (NACT). METHODS: The study group comprised 536 patients with primary breast cancer who underwent NACT followed by immediate IBBR or AFR. After propensity score matching, 138 patients in the IBBR group and 276 patients in the AFR group were selected for comparisons of locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and breast cancer-specific survival (BCSS). RESULTS: No significant differences were observed between the matched groups in locoregional recurrence rates (IBBR vs. AFR: 12.3% vs. 12%; P = 0.915) and distant metastasis (13% vs. 17%; P = 0.293). There was also no significant difference between the groups in LRRFS (P = 0.956), DFS (P = 0.606), DMFS (P = 0.283), or BCSS (P = 0.121). The 5- and 10-year LRRFS rates were 87.6% and 85.9% in the IBBR group, and 87.7% and 86.1% in the AFR group; the 5- and 10-year DFS rates were 79% and 77.5% in the IBBR group, and 77% and 75% in the AFR group; the 5- and 10-year DMFS rates were 85.9% and 85.9% in the IBBR group, and 83.2% and 81.8% in the AFR group; and the 5- and 10-year BCSS rates were 97.8% and 91.3% in the IBBR group, and 91.8% and 86% in the AFR group, respectively. CONCLUSIONS: In this propensity score-matched analysis of oncologic outcomes in breast cancer patients who underwent immediate reconstruction after NACT, no significant differences were observed between the IBBR and AFR groups.

Oncologic Safety of Nipple-Sparing Mastectomy in Patients with Breast Cancer and Tumor-to-Nipple Distance ≤ 1 cm: A Matched Cohort Study.

BACKGROUND: A short tumor-to-nipple distance (TND) is reported as a strong predictor of nipple-areola complex (NAC) involvement. Eligibility for nipple-sparing mastectomy (NSM) remains controversial, especially regarding TND. In this study, we compared long-term oncologic outcomes after NSM between patients with a TND ≤ 1 cm and those with a TND > 1 cm. METHODS: Overall, 1369 patients with primary breast cancer who underwent NSM with immediate reconstruction from March 2003 to December 2015 were included for analysis. After propensity score matching, 495 patients with a TND ≤ 1 cm (group A) and 495 patients with a TND > 1 cm (group B) on imaging were selected to compare long-term oncologic outcomes. RESULTS: After matching, the median follow-up periods for surviving patients were 109 months and 112 months for groups A and B, respectively. There were no significant differences between groups with respect to the 5-year cumulative local recurrence (8.1% vs. 6.3%; p = 0.268), NAC recurrence (5.1% vs. 2.8%; p = 0.072), regional recurrence (2.0% vs. 3.6%; p = 0.125), or distant recurrence (5.9% vs. 4.8%; p = 0.480) rates. Furthermore, no significant differences were observed between the groups with respect to the 10-year local recurrence-free survival (87.1% vs. 90.7%; p = 0.164) or disease-free survival (77.9% vs. 81.6%; p = 0.222) rates. CONCLUSIONS: A preoperative TND ≤ 1 cm on imaging should not be contraindicated to NSM as long as there is no involvement of NAC clinically or on imaging and if retroareolar margins are confirmed to be negative for tumor cells.

Inframammary Fold Approach for Second-stage Operation in Expander-Implant Breast Reconstruction.

BACKGROUND AND OBJECTIVES: Despite expander-based breast reconstruction being used as a reliable reconstruction method, implant removal due to wound dehiscence and infection still occurs in 0.5% to 15% of cases. This study aimed to compare the outcomes of the new inframammary fold (IMF) incision approach with previous incision in second-stage operation of expander-based 2-stage breast reconstruction. METHODS: Patients who underwent expander-based 2-stage breast reconstruction between February 2014 and May 2019 were included. After expander inflation, patients undergoing second-stage reconstruction were divided into the previous incision and IMF incision groups and their outcomes were compared. Propensity score matching analysis was performed to compare postoperative 1-year results. RESULTS: The previous incision and IMF incision groups comprised 79 and 31 patients, respectively. There were no intergroup differences in general demographics or intraoperative data, except for total inflation volume (426.87 ± 102.63 mL in the previous incision group and 375.48 ± 94.10 mL in the IMF incision group, P = 0.017). Wound dehiscence occurred in 12 and 0 cases in the previous and IMF incision groups, respectively (P = 0.018). Implant removal was performed due to dehiscence in 9 cases (8.18%) and 0 cases (0%) in the previous and IMF incision groups, respectively (P = 0.049). In 1-to-1 propensity score matching analysis, the IMF incision group showed better results at 1-year follow-up (odds ratio: 0, 95% confidence interval: 0-1.09; P = 0.063). CONCLUSIONS: The IMF approach is a safe method for replacing the expander with an implant, with lower incidence of wound dehiscence and implant explantation.

Recurrence Outcomes After Nipple-Sparing Mastectomy and Immediate Breast Reconstruction in Patients with Pure Ductal Carcinoma In Situ.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become increasingly prevalent for patients with ductal carcinoma in situ (DCIS) requiring mastectomy. However, few data regarding recurrence outcomes after NSM are available for this patient population. This study evaluated the locoregional recurrence (LRR) rate for patients with pure DCIS who underwent NSM followed by immediate breast reconstruction without adjuvant radiotherapy and investigated potential risk factors for LRR and/or nipple-areola complex recurrence (NR). METHODS: A retrospective chart review was performed for 199 consecutive patients with pure DCIS who underwent NSM and immediate breast reconstruction between March 2003 and December 2015. Risk factors for LRR and NR were analyzed using univariate (Chi square test) and multivariate (Cox model) methods. RESULTS: The median follow-up duration after surgery was 97 months (range, 39-186 months). At 10 years, the LRR rate was 4.5%, and the NR rate was 3%. The univariate analysis showed that high nuclear grade, negative receptor status, positive human epidermal growth factor receptor 2 (HER2) status, and negative hormone receptor/positive HER2 subtype were associated with increased risk for NR. The multivariate analysis demonstrated that negative progesterone receptor status was an independent risk factor for LRR. However, margin status and tumor-to-nipple distance (TND) were not associated with increased risk for either LRR or NR. CONCLUSIONS: The study findings suggest that NSM can be a feasible surgical option even for DCIS with a TND of 1 cm or less if the retroareolar resection margin is negative for malignancy. Determining the molecular subtype of DCIS might be helpful in identifying patients at high risk for recurrence.

Comparison of transverse upper gracilis and profunda femoris artery perforator flaps for breast reconstruction: A systematic review.

BACKGROUND: Thigh-based flaps are generally considered a secondary option for breast reconstruction, with inner thigh-based transverse upper gracilis (TUG) flaps being the preferred choice for many surgeons; however, its well-established drawbacks include short pedicle length, lack of volume, and donor morbidity. The posterior thigh-based profunda femoris artery perforator (PAP) flap was introduced as an alternative approach, but these flaps were not comparatively analyzed with TUG flaps on a large scale. We aimed to systematically review TUG- and PAP-flap breast reconstruction to determine the better secondary option. METHODS: We performed a systematic review of the literature using the PubMed database. Our selected series for systematic analyses included 613 TUG flaps in 432 patients and 475 PAP flaps in 329 patients. Elementary data on the flaps and complications were collected and analyzed. Pooled estimates of proportions of flaps with recipient complications and donor site morbidity were compared using random effect single arm meta-analysis. RESULTS: The basic patient demographics were comparable between the flap types. The mean operation time was comparable. The PAP flap had longer pedicle length and higher flap weight. The total loss (p = .6579), partial loss rate (p = .3247), and fat necrosis rate (p = .0771) were comparable between flap types. Regarding donor morbidity, the PAP flap group had less wound dehiscence (p < .0001) and lower rate of sensory disturbance (p < .0001). CONCLUSIONS: The study findings indicate that the PAP flap, when compared with the TUG flap, could be a better secondary option for breast reconstructions.

Safety of Retrograde Flow of Internal Mammary Vein: Cadaveric Study and Anatomical Evidence.

BACKGROUND: Additional second vessels may be required to handle multiple flaps used to add breast volume, boost blood flow for supercharging, or use salvage recipient vessels. In these situations, retrograde internal mammary vessel flow can be used although this causes doubts and concerns. PATIENTS AND METHODS: Forty sides of the chests of 20 fresh cadavers with intact thoracic cages and internal mammary veins (IMV) were used in the study. IMV valve numbers and locations were checked, and the bifurcation was confirmed. A retrograde fluorescent angiography and a saline infusion test were followed to confirm flow direction. RESULTS: Twenty-eight vessels were identified in 40 sides of the chest; of them, 45% had no valves. A mean 0.7 valves per chest side were identified; 23 (82.1%) of 28 valves were located above the second intercostal space (ICS). A mean 1.76 communicating veins were found between the IMV bifurcation. In all cadavers, a crossing vein connecting the left and right medial IMV was confirmed just below the xiphoid process. Fluorescent angiography and a saline infusion test proved that the retrograde flow was caudal through the bifurcated IMV to the communicating, intercostal, and crossing veins. CONCLUSION: The IMV valve was present in 55% of our subjects and located concentrically above the second ICS level. It is highly unlikely that the retrograde flow was disturbed because the retrograde anastomosis level was below the second ICS. Furthermore, the bifurcation, intercostal, and crossing veins across the xiphoid process enabled valve-less detour flow. Thus, retrograde IMV flow is considered safe.