Identifying the Variables for Oncoplastic Reconstruction: Preoperative Assessment Tool for Breast Conserving Treatment.

BACKGROUND: A wide range of surgical techniques has been described for breast conservation treatment (Oncoplasty) based on breast size and shape, as well as tumor size and location. However, there is a lack of standardization regarding the indications for oncoplastic reconstruction. This study aims to identify the presurgical parameters associated with poor cosmetic outcomes post-breast conserving treatment. We hope this preoperative model can assist in evaluating whether there is a need for oncoplastic intervention. METHODS: The study group involved 136-adult females (age 35-77) who previously undergone breast conserving surgery and radiation, without oncoplastic intervention between 2007 and 2017. Patient demographics, medical and physical parameters were collected, and each patient filled Breast-QTM-questionnaire and six angles' photographs were taken. Patients' photographs were evaluated by 15 board-certified plastic surgeons. Both univariate and multivariate logistic regression analysis was performed to identify potential confounders for poor outcome in each of the experts' and patients' average-grades. RESULTS: Our analysis identified several variables correlated with poor surgical outcome: high BMI, high chest-wall-circumference, high breast-width and larger volume-removed. The general-aesthetic-result as evaluated by our experts was favorably influenced by an upper lateral quadrant tumor while the breast shape was negatively influenced by a lower medial quadrant tumor. Interestingly, no correlation was found between the patients' and panel's evaluations, nor did we find any clinically significant parameter related to the patients' reported well-being. CONCLUSION: Patients with high BMI, high chest-wall-circumference, large breast-width and larger inferomedial tumors could benefit from early plastic surgery evaluation and intervention. Patient's psychosocial well-being as well as sexual well-being are independent from positive surgical outcome evaluated by plastic surgeons. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evolving Trends in Breast-Implant-Based Procedures in Israel: A National Survey.

Rare reports linking textured breast implants to anaplastic large-cell lymphoma have generated controversies regarding their relative advantage over smooth implants. To evaluate trends in implant use in Israel, we sent a seven-item questionnaire to all active board-certified breast plastic surgeons in the country. About half responded. Approximately 60% of responders reported a moderate-to-considerable decrease in both the relative number of augmentation mammoplasty procedures and the use of implants during mastopexies in the last year. Nearly 40% had switched from textured to smooth implants to some extent. More than 40% still used textured implants for aesthetic procedures, and reconstructive procedures. Surgeons with more experience demonstrated a greater preference for smooth implants. The uncertainty regarding the safety of textured breast implants has led to a partial transition to the use of smoother implants and, importantly, to a general reduction in all breast-implant-based procedures.

Complicated wound closure following mastectomy and breast reconstruction.

Breast reconstruction incidence increased, including preventive surgery. In this context, providing women best surgical care and results is crucial, with minimum complications, such as wound dehiscence and skin flap necrosis. Tension-free closure of skin flaps is mandatory for successful healing. However, since this is not always possible, various techniques have been developed to reduce tension from wound margins, facilitate primary wound closure, and minimize and improve scarring. These techniques have not been investigated in breast surgeries. The aim of this study was to describe our experience with the Tension-Relief System in mastectomy and breast reconstructive patients, and the advantages of using this technique. The retrospective cohort consisted of 13 breasts of 11 women aged 29-74 years who underwent surgery with primary wound closure using the System, in 2019-2020 in our department. It was applied averagely 19.7 days, demonstrated effectiveness in preventing complications and as secondary treatment following complications. This enabled avoiding further and more extensive surgeries, including donor-site morbidity when needed. In mastectomy and breast reconstruction, the system minimizes complications and yields satisfactory esthetic and functional outcomes, with minimal inconvenience to the patient, and good pain control. The technique is low-cost, simple to use, and does not require special settings, surgical equipment, or particular skills.

Use of the Subfascial Plane for Gender-affirming Breast Augmentation: A Case Series.

Transgender women seeking gender-affirming breast augmentation often present with differences in preoperative chest measurements and contours in comparison with cisgender women. These include a more robust pectoralis muscle and limited glandular tissue, raising important considerations in determining the optimal anatomical plane for implantation. Abundant literature has described advantages and drawbacks of the available planes for breast augmentation in cisgender women. Certain drawbacks may be more pronounced for transgender women, given their distinct anatomy. The subfascial plane offers lower complication rates than the subglandular plane when using smooth implants, and avoids implant animation and displacement associated with the subpectoral plane. To our knowledge, existing studies have not yet addressed this discussion in the transfeminine population. The goal of this article is to highlight potential benefits of the subfascial plane for gender-affirming breast augmentation, utilizing a case series of 3 transfeminine patients, and to review the literature on surgical techniques and outcomes in this population. METHODS: A retrospective chart review of patients presenting to a single surgeon for gender-affirming breast augmentation in 2019 was performed. A narrative literature review on surgical techniques and outcomes for gender-affirming breast augmentation was conducted. RESULTS: Three cases of gender-affirming breast augmentation using subfascial implant placement are described. From the literature search, 12 articles inclusive of 802 transfeminine patients were identified. CONCLUSIONS: The subfascial plane represents an option for implant placement in gender-affirming breast augmentation that merits further investigation. There is a need for more research comparing surgical techniques and outcomes in the transfeminine population.

Immediate Breast Reconstruction: Comparative Outcome Study of One-Stage Direct-to-Implant and Two-Stage/Tissue Expander Techniques.

BACKGROUND: One-stage direct-to-implant post-mastectomy breast reconstruction has been gaining popularity over the traditional two-stage/tissue-expander approach. OBJECTIVES: To evaluate the outcome of the two post-mastectomy breast reconstruction procedures in terms of patient satisfaction. METHODS: Clinical data were collected by file review for patients who underwent mastectomy with immediate breast reconstruction at two tertiary medical centers in 2010-2013. Patients were asked to complete the BREAST-Q instrument, sent to them by post with a self-addressed, stamped, return envelope. Scores were compared by type of reconstruction performed. RESULTS: Of the 92 patients who received the questionnaire, 59 responded: 39 had one-stage breast reconstruction and 20 underwent two-stage reconstruction. The two-stage reconstruction group was significantly older, had more background diseases, and were followed for a longer period. The one-stage reconstruction group had a higher proportion of BRCA mutation carriers. There was no significant between-group difference in postoperative complications. Mean BREAST-Q scores were similar in the two groups for all dimensions except satisfaction with information, which was higher in the patients after one-stage reconstruction. Women with more background diseases had better sexual well-being, and married women had better psychological well-being. Breast satisfaction was lower among patients treated with radiation and higher among patients with bilateral reconstruction; the latter subgroup also had higher physical well-being. Complications did not affect satisfaction. CONCLUSIONS: Patients were equally satisfied with the outcome of one- and two-stage breast reconstruction. The choice of technique should be made on a case-by-case basis. Cost analyses are needed to construct a decision-making algorithm.

Chest Wall-Based Flap for Repairing Partial Mastectomy Defects: A Multipurpose Flap.

OBJECTIVE: The objective of this study is to introduce a single and reproducible tissue-rearrangement oncoplastic technique that is applicable for all quadrants partial-mastectomy defects in small- to medium-sized breasts, using grounds drawn from cosmetic surgery. METHODS: Eleven small- to medium-sized breast cancer patients with tumor involvement of more than a quarter of the breast were operated on using the chest wall-based flap technique. The procedure is described in detail, and the results are analyzed in terms of both cosmetic and oncological results. RESULTS: The flap successfully reached all breast quadrants as necessary, as well as the areola-nipple complex. The resection borders were found to be free of tumor in all cases, and there were no perioperative complications. Patients rated nearly all the cosmetic parameters as "somewhat satisfied" or "very satisfied," and there was no evidence of fat necrosis in the postoperative mammography examinations. CONCLUSIONS: Applying principles taken from the cosmetic plastic surgery lies at the base of any high standard reconstructive surgery in general and oncoplastic breast surgery in particular. The chest wall-based flap is suitable for the reconstruction of a wide range of breast lumpectomy defects and is feasible for small- to medium-sized breasts, which are usually not easily amenable to tissue rearrangement techniques. The learning curve is short, with replicable results.

[PARTIAL BREAST RECONSTRUCTION BY MODIFIED BREAST REDUCTION TECHNIQUES].

INTRODUCTION: Partial resections of the breast are more than 50% of breast oncological surgery. The resulting defect can be substantial and cause meaningful deformity that leads to reduced body image satisfaction of the patients, affecting their ability to cope with the cancer. Parallel to the development of breast oncology techniques, an evolution of breast reconstruction techniques occurred. During the last decade, by using techniques from cosmetic breast surgery (such as breast reductions, augmentations and mastopexies), we can reconstruct extensive partial defects of the breasts at the immediate and delayed setting and achieve symmetrical aesthetic results. Of the 350 oncological breast surgeries a year performed in our center, 70% undergo partial breast resection and only 10% of those surgeries exhibit a defect necessitating reconstruction. The recovery and post-operative complications, especially in the immediate setting, are significantly reduced in comparison to total breast reconstruction. Our experience shows that by using plastic surgery techniques in those operations, we can overcome the deformity created by large partial resection of the breast and improve the mental recovery from breast cancer.

Large-volume breast reduction: Long-term results.

Forty-three women had reduction mammaplasty during the period 1992-2000 and the cosmetic outcome was evaluated using subjective and objective measures. The inferior pedicle technique was used in all cases. The mean (SD) weight of resected tissue was 1121 (415) g. All objective measurements were within the ideal range except for breast volume and nipple-to-inframammary-line distance, which were more than ideal. Overall, the median difference in measurements between the two breasts of each woman was less than 10%. However, the subjective evaluations given by both clinicians and the patients for overall symmetry and for general aesthetic appearance fell below the preset threshold. The shape of the breast correlated best with the grades of symmetry and general appearance. There was no correlation between the objective and subjective evaluations of symmetry. The disappointing subjective scores, which may be attributed to the specific characteristics of our sample group, are heavy breasts and overweight patients, a double team approach, and the inevitable pseudoptosis that develops with the inferior pedicle approach. These direct us to recommend searching for an alternative operative technique and to evaluate its long term results, as well as placing the nipple-areola complex lower than the standard inframammary fold projection.

Prediction of morbidity and mortality on admission to a burn unit.

BACKGROUND: Improvements in burn care during the last two decades call for new prediction models of morbidity and mortality. The aim of the study was to identify parameters that are predictive of major morbidity factors and risk of mortality in patients with burn injury. METHODS: The charts of 249 patients (236 survivors) aged 1 to 94 years who were treated for second- and third-degree burns from 1995 to 2002 were reviewed. A multivariate linear stepwise regression model was fitted to the data to predict length of hospitalization, length of operations, and mortality rate. RESULTS: Survivors' mean burn size was 14 +/- 15 percent of the total body surface area (range, 5 to 90 percent), with a mean hospitalization time of 22.9 +/- 17.1 days and a mean operative time of 127.5 +/- 166.8 minutes. The prognostic factors in each of the regression models predicted 40 percent and 55 percent of the variance in length of hospital stay and operative time, respectively. Total body surface area alone explained most of the variance (29 percent and 44 percent, respectively). As a result, the authors created shorter formulas: Length of hospitalization (days) = 18 + [total body surface area]/3; Operative time (minutes) = 55 + 4[total body surface area]. Total body surface area and smoke inhalation were the only statistically significant predictors of death. Every 1 percent increase in total body surface area was associated with a 6 percent increase in mortality risk. The presence of smoke inhalation increased mortality risk by nine-fold. CONCLUSIONS: Using objective measurements in burn treatment is of great importance. The formulas presented by the authors explain a considerable percentage of the probability of morbidity in burn victims. The authors suggest that other burn units develop their own statistically supported prediction models.