Oncological Safety of Oncoplastic Level II Mammoplasties After Neoadjuvant Chemotherapy for Large Breast Cancers: A Matched-Cohort Analysis.

BACKGROUND: Oncoplastic surgery (OPS) has extended the indications for breast-conserving surgery (BCS). Its role in patients with large breast cancers treated with neoadjuvant chemotherapy (NAC) is unclear. This study evaluated the oncological safety of OPS for tumors with partial response after NAC. METHODS: A consecutive series of 65 patients who underwent OPS (study group) after NAC for large breast cancer from January 2004 to July 2018 was compared with 130 matched patients treated by NAC, followed by standard BCS in 65 cases and mastectomy in 65 cases (two case-controlled groups). RESULTS: The mean initial radiological tumor size was 46 mm. Residual pathological tumor size was 22 mm in the OPS cohort, 19 mm in the standard BCS cohort, and 31 mm in the mastectomy cohort (p > 0.05). The mean follow-up was 59 months in the study cohort. Five-year local recurrence rates were 0%, 0%, and 10.5% (0-22%) for the OPS, BCS, and mastectomy cohorts, respectively, while 5-year regional recurrence rates were 4.1% (0-11.1%), 0, and 19.4% (0-35.2%, p > 0.05), respectively. Five-year overall survival was 85.3% for the OPS cohort, 94.1% for the standard BCS cohort (p = 0.194), and 79.9% for the mastectomy cohort (p = 0.165). CONCLUSIONS: OPS is safe after NAC for large breast cancers, and provides excellent local control, identical to that of tumors with a better response, treated by standard BCS. After NAC, OPS can be a valuable treatment option for tumors that did not shrink optimally and would not be suitable for standard BCS.

Lessons Learned From Twenty-Eight Cases of Burns Following Breast Reconstruction: An Underestimated Complication Requiring Inclusion in Consent Information.

BACKGROUND: There has over recent years been a constant increase in annual breast reconstruction figures. Although reports indicate that burns following breast reconstruction are a rare occurrence, there has nevertheless been a relative increase in cases. The key underlying causes of this type of condition remain unknown. OBJECTIVES: The authors launched a new study on the demographic characteristics of burns in the breast reconstruction population with the inclusion of up-to-date data to assess cases and contributing factors. METHODS: The study was a multicenter retrospective review of patients who underwent any type of breast reconstruction and subsequently sustained burn injuries. RESULTS: Twenty-eight cases of burn injury following breast reconstruction were documented; 6 involved autologous flaps and 22 involved implants. Nine of the 10 implant exposure cases had previous history of radiotherapy, but there was no statistically significant difference between previous radiotherapy history and implant exposure (P = 0.32). Of the 13 cases sustaining full-thickness burns, a large number included implant-based reconstruction (n = 12, 92%), although no statistically significant difference was observed between type of reconstruction and incidence of full-thickness burns (P = 0.17). CONCLUSIONS: Each patient undergoing breast reconstruction should be advised of the potential risks and instructed to avoid significant heat exposure and steer clear of dark-colored bathing suits. At the time of writing, this information has yet to be included in the vast majority of surgery-related informed consent documents.

Long-term Results After Oncoplastic Surgery for Breast Cancer: A 10-year Follow-up.

OBJECTIVE: The aim of this study was to evaluate the long-term oncologic outcome after oncoplastic surgery (OPS). BACKGROUND: OPS combines wide tumor excision with reduction mammoplasty techniques thus extending breast conserving surgery to large tumors that might else be proposed a mastectomy. Little data are available about the oncologic results for breast conserving surgery of these larger tumors. METHODS: From January 2004 until March 2016, a total of 350 oncoplastic breast reductions were prospectively entered into a database. Patients were included if their breast reshaping included a reduction mammoplasty with skin excision (Level 2 oncoplastic techniques). RESULTS: Histologic subtypes were: invasive ductal carcinoma in 219 cases (62.6%), ductal carcinoma in situ (DCIS) in 88 cases (25.1%), and invasive lobular carcinoma in 43 (12.3%) cases. Seventy-three of the invasive cancers (27.9%) received neoadjuvant chemotherapy. The mean resection weight was 177 grams. The mean pathological tumor size was 26 mm (range 0-180 mm) and varied from 23 mm (4-180 mm) for invasive cancers to 32 mm (0-100 mm) for DCIS. Specimen margins were involved in 12.6% of the cases; 10.5% of invasive ductal, 14.7% of DCIS, and 20.9% of invasive lobular. The overall breast conservation rate was 92% and varied from 87.4% for DCIS to 93.5% for the invasive cancers. Thirty-one patients (8.9%) developed one or more postoperative complications, inducing a delay in postoperative treatments in 4.6% of patients. The median follow up was 55 months. The cumulative 5-year incidences for local, regional, and distant recurrences were 2.2%, 1.1%, and 12.4%, respectively. CONCLUSIONS: Oncoplastic breast reductions allow wide resections with free margins and can be used for large cancers as an alternative to mastectomy.

Positive Margins After Oncoplastic Surgery for Breast Cancer.

BACKGROUND: Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge. METHODS: All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'. RESULTS: A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %. CONCLUSIONS: Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.

Oncoplastic surgery: pushing the limits of breast-conserving surgery.

In recent decades, the surgical management of breast cancer has steadily and considerably improved. Mutilating procedures have given way to more individualized surgical approaches aiming to preserve the breast as much as possible. For large tumors, preoperative chemotherapy is a major tool, but emerging oncoplastic surgery techniques are also a new approach in the armamentarium of breast cancer surgery, as a third option between conventional breast-conserving surgery and mastectomy. As this new treatment modality allows wider margin excision, it reduces the need for re-excision procedures and possibly increases breast conservation rates by extending the indications of breast-conserving surgery. This review will provide an overview of current practices and clinical data available to date on oncoplastic surgery.

Level 2 oncoplastic surgery for lower inner quadrant breast cancers: the LIQ-V mammoplasty.

BACKGROUND: Oncoplastic surgical techniques offer an option of breast conserving surgery for larger tumors with the use of glandular reshaping to prevent postoperative deformity. A technique for the excision of lower inner quadrant tumors via a V incision is described, the lower-inner quadrant-V (LIQ-V) mammoplasty, and the results of a pilot study are reported. METHODS: Retrospective collection of pre- and postoperative data was collected from patients undergoing a LIQ-V mammoplasty for a LIQ tumor. RESULTS: Twenty-two patients were operated on between 2004 and 2011 at a mean age of 58 years. The mean follow-up was 55 months. The mean resection weight was 101 g for tumors ranging in size from 4 to 31 mm. The margins were clear in 95% of cases. There was one case of local recurrence and metastatic disease. The cosmetic outcome was judged as excellent in 68% of cases, and no patient required further ipsilateral or contralateral symmetrizing surgery. DISCUSSION: The deformity often associated with tumors of the LIQ is adequately addressed by this new technique. It has a complication rate comparable to other mammoplasty series and a high rate of clear resection margins. Many oncoplastic surgery techniques are based on inverted T mammoplasty, but these are not suited for all tumor locations. The LIQ-V mammoplasty is an adaptation of the standard techniques that best suit the LIQ. It is oncologically safe and provides disease-free margins, and although the resection volumes are large, the cosmetic outcome is not compromised.

Oncoplastic technique for the elimination of the lateral "dog ear" during mastectomy.

Following a mastectomy, both the cosmetic and functional results can be impaired by the presence of a lateral "dog ear." This is a particular problem in women with a large body habitus giving an increased amount of adipose tissue lateral to the breast. The standard approaches to this operation of horizontal or oblique incisions often results in an uncomfortable, unsightly lateral "dog ear". We describe a modification to the standard mastectomy incision that allows extensive excision of the lateral adipose tissue, re-draping the skin over the chest wall, thus eliminating the "dog ear." The mastectomy is performed through two oblique incisions originating in the axillary skin crease encompassing the nipple areolar complex, followed by extensive lateral fat excision. A distance of 2-3 cm is kept between the superior limit of the two incisions. At closure the lateral skin flap is advanced superiomedially on the chest wall without tension. This simple and reproducible technique improves cosmesis and patient satisfaction following modified radical mastectomy by eliminating the lateral "dog ear."

Avoiding post mastectomy lateral "Dog Ears" by an L incision and lipoaspiration: The Paris Breast Center technique.

BACKGROUND: Lateral dog ear after mastectomy in overweight or large breasted patients is a source for patient discomfort and is aesthetically unpleasing. Although many different techniques have been proposed, none of them have emerged as standard. In 2012, the authors published their mastectomy technique based on an inverted L-scar incision and closure with a lateral skin flap advanced supero-medially onto the chest wall. Authors sought to report their experience with this technique in patients with wide or large breasts operated with mastectomy without immediate breast reconstruction. As a refinement to their initial technique, they added lipoaspiration to the lateral chest wall. METHODS: A retrospective study identified 43 patients operated on using the L incision and lipoaspiration from January 2015 to January 2021. Patient and tumor characteristics, operative details, post-operative results, and complications were recorded. Patients were followed-up and assessed for arm motion restriction, lymphedema, and recurrence. RESULTS: The mean age was 68 years; the mean BMI was 29 kg/m 2. The mean follow-up was 32 months. The mean weight of the mastectomy specimen was 1009 g and the mean aspirated volume in the lateral chest wall was 450 mL. One patient had a hematoma, four patients had seroma, and one patient developed a minor wound dehiscence. No skin necrosis or arm movement restriction was observed. Two patients developed mild lymphedema. Three patients underwent delayed breast reconstruction. CONCLUSION: The proposed technique is a safe and effective method to avoid lateral dog deformity after mastectomy, achieving both functional and cosmetic outcomes.

Fat Grafting before Delayed Prophylactic Mastectomy and Immediate Implant Reconstruction for Patients at High Risk of Complications.

SUMMARY: The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery.

BACKGROUND: Oncoplastic surgery (OPS) has emerged as a new approach for extending breast conserving surgery (BCS) possibilities, reducing both mastectomy and re-excision rates, while avoiding breast deformities. OPS is based upon the integration of plastic surgery techniques for immediate reshaping after wide excision for breast cancer. A simple guide for choosing the appropriate OPS procedure is not available. OBJECTIVE: To develop an Atlas and guideline for oncoplastic surgery (OPS) to help in patient selection and choice of optimal surgical procedure for breast cancer patients undergoing BCS. METHODS: We stratify OPS into two levels based on excision volume and the complexity of the reshaping technique. For resections less than 20% of the breast volume (level I OPS), a step-by-step approach allows easy reshaping of the breast. For larger resections (level II OPS), a mammoplasty technique is required. RESULTS: We identified three elements that can be used for patient selection and for determination of the appropriate OPS technique: excision volume, tumor location, and glandular density. For level II techniques, we defined a quadrant per quadrant Atlas that offers a different mammoplasty for each quadrant of the breast. CONCLUSIONS: OPS is the "third pathway" between standard BCS and mastectomy. The OPS classification and Atlas improves patient selection and allows a uniform approach for surgeons. It proposes a specific solution for different scenarios and helps improve breast conservation outcomes.

Salvaging the infected breast implant: results of a retrospective series of 80 consecutive cases.

BACKGROUND: Breast implants are widely used in reconstruction after breast cancer. Infection after implant reconstruction is a major complication, with rates ranging from 5 to 30%. This rate is less for pure cosmetic augmentation. Historically, infection of an implant mandated implant removal for sepsis control. An alternative is to attempt to salvage the infected implant. This path can be a long one, requiring surgery for washouts and prolonged antibiotic therapy. This article documents our experience of infected implant salvage over the last 13 years. METHODS: We conducted a retrospective analysis of all patients who developed a breast implant infection between January 2005 and January 2018. All patients had both clinical signs of infection and a positive bacteriological sample. Patients were divided into two groups: upfront medical therapy (including those requiring secondary surgical salvage) and primary surgery. The salvage procedure was defined as successful when the implant was still in place three months after the initial reconstruction. RESULTS: Eighty patients were included: 77 in the medical group and 3 in the surgical group. Overall, implant salvage was achieved in 88.8% of women (n=71). Of these, 73.8% (n=59) underwent medical treatment alone and 15% (n=12) underwent medical treatment followed by surgical management. The main causative organism was staphylococcus in 81.2%. When the infection was caused by a coagulase-negative staphylococcus, the rate of success was 98% (p<0.003). CONCLUSIONS: This case series reports that salvage of an infected breast implant was achievable in up to 90% of women presenting with a documented infection, the majority requiring antibiotic management only. Early intervention is central to success.

Breast-conserving therapy can be offered to women with prior breast augmentation.

INTRODUCTION: Breast cancer in women with cosmetic breast implants is increasingly common. Over the past decade, there has been a push for mastectomy and reconstruction in these patients, based on a fear of poor aesthetic results from small breast volume, and radiation-induced capsular contracture. At the Paris Breast Centre, augmented women routinely undergo lumpectomy with whole-breast irradiation (BCT). MATERIALS AND METHODS: A consecutive cohort of 50 augmented women, who had attempted BCT for early breast cancer at our institution between 2003 and 2018, were retrospectively identified. Post-treatment complications, oncologic outcomes, capsular contracture rates, long-term cosmetic outcomes, and patient-reported outcomes were evaluated. RESULTS: The median follow-up was 51 months. Margins were involved in 7 women (14%); 4 of whom underwent successful re-excision, and 3 had a mastectomy, for an early mastectomy rate of 6%. There were no early complications, nor cases of early implant loss. Long-term aesthetic results were evaluated using our 5-point scale: An excellent (5), or good (4) result was obtained in 68%. Significant capsular contracture (Baker grade 3 or 4) developed in 34%, of which, 5 women underwent capsulotomy and fat grafting; 4 of 5 downstaging their Baker grade. The estimated 5-year local recurrence rate was 2.3%. Ninety-five percent of participants would recommend BCT to augmented women. CONCLUSION: BCT is feasible and safe in augmented women with good long-term aesthetic results, and should be considered to avoid unnecessary mastectomy.

Safety and Efficacy of Stabilized Hyaluronic Acid Gel for Breast Enhancement.

Long-term follow-up data following 2 breast enhancement treatments with stabilized hyaluronic acid (HA) gel are limited. Although HA gel is no longer marketed for breast enhancement, there is a clinical need for information about follow-up of previously treated women. A multicenter, noncomparative study was conducted in women seeking breast enhancement. Subjects received 1 treatment of HA gel (maximum, 100 mL/breast); a subgroup underwent retreatment 9 months later. Follow-up was conducted for 24 months after last treatment; endpoints included magnetic resonance imaging for estimation of gel degradation, adverse events, breast examinations, Global Esthetic Improvement Scale, and satisfaction ratings. Seventy-one subjects received 1 treatment, with 22 (31%) receiving retreatment after 9 months. Twenty-four months after last treatment, the mean percentage of remaining gel was 17% in the single-treatment group and 21% in the retreatment group; complete degradation had not occurred in any subject. The most commonly reported treatment-related adverse events were implant-site nodules, medical device implantation events, capsular contracture associated with breast implant, and injection-site nodules; most were mild to moderate and required no intervention. Based on subject Global Esthetic Improvement Scale ratings, 36% of breasts in the single- treatment group and 50% of breasts in the retreatment group were improved 24 months after last treatment, but subject satisfaction had returned to baseline levels. Some gel remained in all subjects 24 months after last treatment. Although single treatment and retreatment were generally well tolerated, physicians need to be aware of common treatment-related complications to manage them adequately.

Safety of Lipofilling in Patients with Breast Cancer.

Lipotransfer represents a technical revolution in plastic surgery and is increasingly used worldwide. Although known for several decades, lipofilling has only recently found widespread use in patients with breast cancer to improve the results of breast reconstructions and to correct deformities after conservative treatment. The plastic surgery literature underlines the technique's versatility and the quality of the results, showing lipofilling as an effective cosmetic procedure and proposing it as a safe, neutral biological material that is able to restore the body contour. Several studies underline the power of transferred fat to regenerate blood supply in skin disorders following radiotherapy.

A position statement on optimizing the role of oncoplastic breast surgery.

OBJECTIVES: To propose initiatives and actions that could improve access to and outcomes from oncoplastic breast surgery. METHODS: The author group met in May 2010 to draft position statements on key unmet needs in oncoplastic breast surgery and how these may be addressed. At a second meeting in December 2010, the statements were voted upon and adjusted as necessary to achieve unanimous agreement. RESULTS: It was agreed that every patient undergoing breast cancer surgery should be assessed by an oncoplastic team capable of offering the full range of surgical options. However, currently, not all women are adequately informed about the surgical options available. Furthermore, levels of multidisciplinary working, standards of care, and levels of surgical training in the full range of breast oncoplastic techniques are suboptimal. Institution-specific guidelines relating to the optimal patient pathway, the definition of clinical standards, and improved education in reconstructive surgery are required. Oncoplastic breast surgery should be offered to all patients, within the context of multidisciplinary teams that include accredited surgeons who consult with each other early in the treatment pathway. These teams should be focused on achieving not just positive oncologic outcomes, but also esthetic outcomes in line with patient wishes, to achieve optimal quality of life. CONCLUSIONS: There is a desire within the surgical community to improve patient outcomes by better incorporating oncoplastic procedures into the treatment pathways for breast cancer. These position statements represent the perspectives of a group of European plastic surgeons on the key elements required to achieve this goal.

The oncologic outcome and immediate surgical complications of lipofilling in breast cancer patients: a multicenter study--Milan-Paris-Lyon experience of 646 lipofilling procedures.

BACKGROUND: Lipofilling is now performed to improve the breast contour, after both breast-conserving surgery and breast reconstruction. However, injection of fat into a previous tumor site may create a new environment for cancer and adjacent cells. There is also no international agreement regarding lipofilling after breast cancer treatment. METHODS: The authors included three institutions specializing in both breast cancer treatment and breast reconstruction (European Institute of Oncology, Milan, Italy; Paris Breast Center, Paris, France; and Leon Berard Centre, Lyon, France) for a multicenter study. A collective chart review of all lipofilling procedures after breast cancer treatment was performed. RESULTS: From 2000 to 2010, the authors reviewed 646 lipofilling procedures from 513 patients. There were 370 mastectomy patients and 143 breast-conserving surgery patients. There were 405 patients (78.9 percent) with invasive carcinoma and 108 (21.1 percent) with carcinoma in situ. The average interval between oncologic surgical interventions and lipofilling was 39.7 months. Average follow-up after lipofilling was 19.2 months. The authors observed a complication rate of 2.8 percent (liponecrosis, 2.0 percent). Twelve radiologic images appeared after lipofilling in 119 breast-conserving surgery cases (10.1 percent). The overall oncologic event rate was 5.6 percent (3.6 percent per year). The locoregional event rate was 2.4 percent (1.5 percent per year). CONCLUSIONS: Lipofilling after breast cancer treatment leads to a low complication rate and does not affect radiologic follow-up after breast-conserving surgery. A prospective clinical registry including high-volume multicenter data with a long follow-up is warranted to demonstrate the oncologic safety. Until then, lipofilling should be performed in experienced hands, and a cautious oncologic follow-up protocol is advised. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV [corrected].

Silicone migration to the contralateral axillary lymph nodes and breast after highly cohesive silicone gel implant failure: a case report.

Highly cohesive silicone gel implants are advertised for aesthetic and safety advantages. Our case is the fourth report describing early implant rupture and contralateral migration of siliconoma. Despite the greater degree of gel cohesiveness, a continued vigilance for signs and symptoms of migration is highly recommended.