Prevention of Postoperative Complications by Prepectoral versus Subpectoral Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Implant-based breast reconstruction has evolved over time. However, the effects of prepectoral breast reconstruction (PBR) compared with those of subpectoral breast reconstruction (SBR) have not been clearly defined. Therefore, this study aimed to compare the occurrence of surgical complications between PBR and SBR to determine the procedure that is effective and relatively safe. METHODS: The PubMed, Cochrane Library, and EMBASE databases were searched for studies published until April of 2021 comparing PBR and SBR following mastectomy. Two authors independently assessed the risk of bias. General information on the studies and surgical outcomes were extracted. Among 857 studies, 34 and 29 were included in the systematic review and meta-analysis, respectively. Subgroup analysis was performed to clearly compare the results of patients who underwent postmastectomy radiation therapy. RESULTS: Pooled results showed that prevention of capsular contracture (OR, 0.57; 95% CI, 0.41 to 0.79) and infection control (OR, 0.73; 95% CI, 0.58 to 0.92) were better with PBR than with SBR. Rates of hematoma, implant loss, seroma, skin-flap necrosis, and wound dehiscence were not significantly different between PBR and SBR. PBR considerably improved postoperative pain, BREAST-Q score, and upper arm function compared with SBR. Among postmastectomy radiation therapy patients, the incidence rates of capsular contracture were significantly lower in the PBR group than in the SBR group (OR, 0.14; 95% CI, 0.05 to 0.35). CONCLUSIONS: The results showed that PBR had fewer postoperative complications than SBR. The authors' meta-analysis suggests that PBR could be used as an alternative technique for breast reconstruction in appropriate patients.

Influence of sarcopenia on postoperative complications in patients undergoing autologous microsurgical breast reconstruction: an inverse probability of treatment weighting analysis.

Background: Sarcopenia is characterized by the loss of skeletal muscle mass and power. Preoperative sarcopenia may be associated with an increased risk of postoperative complications after autologous free-flap breast reconstruction surgery; however, this relationship is controversial. Objectives: This study aimed to determine whether preoperative sarcopenia is associated with a high complication rate in patients undergoing autologous free-flap breast reconstruction. Methods: Patients who underwent autologous free-flap breast reconstruction at our hospital between 2019 and 2021 were included in the study. Data on significant complications requiring surgical intervention were retrospectively collected from the medical records. Sarcopenia was defined as having a skeletal muscle index value <41 cm2/m2. The skeletal muscle index was calculated by dividing the sum of the psoas and iliopsoas muscle areas at the level of the third lumbar vertebra by the patient's height in meters squared. The relationship between preoperative sarcopenia and postoperative complications was investigated using an inverse probability of treatment weighting (IPTW) analysis. Results: Among the 203 participants, 90 (44.33%) had preoperative sarcopenia. The general patient characteristics were similar between the sarcopenia and non-sarcopenia groups after IPTW adjustment. Sarcopenia did not significantly increase the risk of flap failure or emergency surgery related to breast reconstruction before IPTW adjustment. However, after IPTW adjustment, the rates of recipient site infection and hematoma were significantly higher in participants with sarcopenia than in those without sarcopenia (p < 0.001 and p = 0.014, respectively). Conclusion: Preoperative sarcopenia may influence certain complications of autologous free-flap breast reconstruction surgery.

Early experience of direct-to-implant breast reconstruction using acellular dermal matrix after robot-assisted nipple-sparing mastectomy.

BACKGROUND: This study aimed to analyze the novel operative outcomes of breast mound reconstruction followed by robot-assisted mastectomy in retrospective review. METHOD: Patients who underwent nipple-sparing mastectomy with a robotic device (Da Vinci Xi) and immediate prosthetic reconstruction prepectorally via lateral incision from June 2018 to July 2019 were enrolled. Patient characteristics, complications, and satisfaction via BREAST-Q were analyzed. The surgical technique was described in detail. RESULTS: Thirty-nine cases, including 7 bilateral cases (total 46 breasts), underwent robot-assisted nipple-sparing mastectomy followed by immediate prosthetic implant reconstruction prepectorally. The median patient age was 46.63 years (range: 21-63 years). The mean operation time for each prepectoral breast mound reconstruction using the direct-to-implant technique was 126.55 min. Overall satisfaction of robotic use was evaluated as superior to the conventional reconstruction method using BREAST-Q. Major infection was found in seven cases (15.2%), and complete nipple loss was found in three cases (6.6%). Severe complications requiring breast implant removal in the surgical technique occurred in four breasts (8.7%). Two cases were due to the coexistence of infection and skin necrosis; in one case, the skin flap had undergone the congestive phase on postoperative day (POD) 3 and required additional surgery to change the expander. Other complications were resolved by conservative care or minor revision. CONCLUSION: This report is the first concerning robot-assisted NSM followed by prepectoral ADM-wrapped prosthetic reconstruction. In our experience, this procedure seems to be not inferior to other methods. Further prospective research to evaluate oncologic outcomes is warranted.

The Donut DIEP Flap: A Novel Scarless Technique.

Deep inferior epigastric perforator (DIEP) flap surgery is a common technique for breast reconstruction. However, the long and noticeable abdominal scarring is one of its greatest disadvantages. Here, we suggest a minimal scarring DIEP flap harvest with a novel abdominal design. The key to this method is to preserve more skin tissue with a circular design centered around the navel. Three circular incisions are made: (1) the smallest circle represents an incision around the umbilicus; (2) the middle circle with a radius of <3.5 cm indicates skin incision because the donut-like skin paddle between the small and middle circles is included in the flap; (3) the largest circle with a radius of >10 cm represents the extent of flap dissection that was done diagonally from the skin toward the Scarpa's fascia. Pedicle dissection is proceeded with the conventional method. For closure, a purse-string suture is performed with the umbilicus at its center leaving only a single small circular scar around the umbilicus as the final scar. Closure of the donor-site is possible with the patient in a supine or slightly flexed position due to less skin excision. LEVEL OF EVIDENCE: Therapeutic, V.

Prevention and Resolution of Silicone Implant-Related Problems in Secondary Rhinoplasty Using a Cross-Linked Human Acellular Dermal Matrix.

BACKGROUND: Silicone implant augmentation rhinoplasty along with various tip plasties are commonly performed in Asian patients, but a revision rhinoplasty is frequently required because of various problems. Secondary rhinoplasties are often performed using silicone, dermofat, costal cartilage block, or diced rib cartilage, but often result in unsatisfactory outcomes. This study assessed the surgical outcomes and complications of cross-linked acellular dermal matrix (ADM) as an alternative biological substitute for silicone implant in secondary rhinoplasty. METHODS: The authors prospectively studied 56 patients with a minimum follow-up of 1 year among 104 patients who underwent secondary rhinoplasty in their clinic between January of 2015 and December of 2018. Silicone implant, capsule, and scar tissue removal; dorsal augmentation with ADM; and tip plasty using autogenous cartilage were performed for all of them. The results were assessed using the modified Rhinoplasty Outcome Evaluation, consisting of a 10-item questionnaire completed preoperatively, 6 months postoperatively, and over 1 year postoperatively. RESULT: One infection and three cases of excessive resorption were noted, with no other major complications. The mean modified Rhinoplasty Outcome Evaluation score was 31.7 on preoperative evaluation, 77.3 at 6 months postoperatively, and 81.4 at 1 year postoperatively (mean difference, 45.6 and 49.7, respectively; P < 0.001). CONCLUSIONS: Various problems that occur after primary rhinoplasty using silicone implants can be resolved successfully with secondary rhinoplasty by dorsal augmentation using the cross-linked human ADM along with various nasal tip work using autogenous cartilage. Surgical outcome showed favorable resolution of contracture deformities, a low infection rate, firm fixation of the implant, good skin texture/thickness of the skin/soft-tissue envelope, and gain of desired height and dorsal line. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Association between Immediate Breast Reconstruction and the Development of Breast Cancer-Related Lymphedema.

BACKGROUND: With the increasing number of patients undergoing immediate breast reconstruction after mastectomy, the impact of immediate breast reconstruction on the risk of breast cancer-related lymphedema has become an emerging area of interest. This study aimed to identify the association between immediate breast reconstruction and postoperative lymphedema. METHODS: A retrospective cohort study was conducted from 2006 to 2016 with 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without immediate breast reconstruction. After excluding patients with synchronous contralateral breast cancer, lymphedema before mastectomy, history of procedures performed in the axillary region, and follow-up data of less than 1 year, the cumulative incidence of lymphedema after immediate breast reconstruction and after no reconstruction was calculated and compared using multivariate Cox regression analysis. RESULTS: Overall, 5497 patients (mean age, 51.7 years) were included, and 630 developed lymphedema. The 5-year cumulative incidence rate of lymphedema was significantly reduced in patients who underwent immediate breast reconstruction versus control patients (9.6% versus 12.2%; P = 0.02). In the multivariate analysis, immediate breast reconstruction status (hazard ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = 0.042) was an independent predictor for lymphedema. Similar significant associations were observed in the subgroup analyses of patients with a body mass index less than 30 kg/m2 (P = 0.024), in those with fewer than 10 dissected lymph nodes (P = 0.042), or in those with adjuvant radiotherapy (P = 0.048). CONCLUSIONS: Immediate breast reconstruction was associated with a reduced risk of lymphedema. These results may be used for predicting the development of lymphedema following breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Corrigendum: Post-operative complications and nipple necrosis rates between conventional and robotic nipple-sparing mastectomy.

[This corrects the article DOI: 10.3389/fonc.2020.594388.].

Methodology in Conventional Head and Neck Reconstruction Following Robotic Cancer Surgery: A Bridgehead Robotic Head and Neck Reconstruction.

PURPOSE: Robotic head and neck surgery is widespread nowadays. However, in the reconstruction field, the use of robotic operations is not. This article aimed to examine methodologies for conventional head and neck reconstruction after robotic tumor surgery in an effort to obtain further options for future reconstruction manipulations. MATERIALS AND METHODS: A retrospective review of all patients who received head and neck robot surgery and conventional reconstructive surgery between October 2016 and September 2021. RESULTS: In total, 53 cases were performed. 67.9% of the tumors were greater than 4 cm. Regarding defect size, 47.2% of the lesions were greater than 8 cm. In terms of TNM stage, stage 3 disease was recorded in 26.4% and stage 4 in 52.8%. To make a deep and narrow field wider, we changed the patient's posture in pre-op field, additional dissection was done. We used radial forearm flap mostly (62.2%). CONCLUSION: Conventional head and neck reconstruction after robotic ENT cancer surgery is possible. One key step is to secure additional space in the deep and narrow space left after robotic surgery. For this, we opted for a radial forearm flap mostly. This can be performed as a bridgehead to perform robotic head and neck reconstruction.

Initial report of extraperitoneal pedicle dissection in deep inferior epigastric perforator flap breast reconstruction using the da Vinci SP.

The deep inferior epigastric perforator (DIEP) flap has been widely used for autologous breast reconstruction after mastectomy. In the conventional surgical method, a long incision is needed at the anterior fascia of the rectus abdominis muscle to obtain sufficient pedicle length; this may increase the risk of incisional hernia. To shorten the incision, several trials have investigated the use of endoscopic/robotic devices for pedicle harvest; however, making multiple additional incisions for port insertion and operating in the intraperitoneal field were inevitable. Here, we describe the first case, in which a DIEP free flap was successfully made using the da Vinci SP model. Our findings can help surgeons perform operations in smaller fields with a single port in the extraperitoneal space. Moreover, this method is expected to lead to fewer donor-related complications and faster healing.

Robotic harvest of a latissimus dorsi flap using a single-port surgical robotic system in breast reconstruction.

Robot-assisted surgery is evolving to incorporate a higher number of minimally invasive techniques. There is a growing interest in robotic breast reconstruction that uses autologous tissue. Since a traditional latissimus dorsi (LD) flap leads to a long donor scar, which can be an unpleasant burden to patients, there have been many attempts to decrease the scar length using minimally invasive approaches. This study presents the case of a patient who underwent a robot-assisted nipple-sparing mastectomy followed by immediate breast reconstruction with an LD flap using a single-port robotic surgery system. With the assistance of a single-port robot, a simple docking process using a short and less visible incision is possible. Compared to multiport surgery systems, single-port robots can reduce the possibility of collision between robotic arms and provide a clear view of the medial border of the LD where the curvature of the back restricts the visual field. We recommend the use of single-port robots as a minimally invasive approach for harvesting LD flaps.

The effect of early arm exercise on drainage volume after total mastectomy and tissue expander insertion in breast cancer patients: a prospective study.

BACKGROUND: In prosthesis-based breast reconstruction patients, the drain tends to be kept in place longer than in patients who undergo only mastectomy. Postoperative arm exercise also increases the drainage volume. However, to preserve shoulder function, early exercise is recommended. In this study, we investigated the effect of early exercise on the total drainage volume and drain duration in these patients. METHODS: We designed a prospective randomized trial involving 56 patients who underwent immediate breast reconstruction following mastectomy using tissue expanders. In each group, the patients were randomized either to perform early arm exercises using specific shoulder movement guidelines 2 days after surgery or to restrict arm movement above the shoulder height until drain removal. The drain duration and the total amount of drainage were the primary endpoints. RESULTS: There were no significant differences in age, height, weight, body mass index, or mastectomy specimen weight between the two groups. The total amount of drainage was 1,497 mL in the early exercise group and 1,336 mL in the exercise restriction group. The duration until complete removal of the drains was 19.71 days in the early exercise group and 17.11 days in the exercise restriction group. CONCLUSIONS: Exercise restriction after breast reconstruction did not lead to a significant difference in the drainage volume or the average time until drain removal. Thus, early exercise is recommended for improved shoulder mobility postoperatively. More long-term studies are needed to determine the effect of early exercise on shoulder mobility in prosthesis-based breast reconstruction patients.

Robotic DIEP Flap Harvest through a Totally Extraperitoneal Approach Using a Single-Port Surgical Robotic System.

SUMMARY: Deep inferior epigastric artery perforator (DIEP) flap surgery is one of the most common techniques for breast reconstruction using abdominal tissue. Although the DIEP flap reduces donor-site morbidity when compared with the conventional free transverse rectus abdominis musculocutaneous flap, violation of the anterior rectus sheath, rectus muscle, and motor nerves cannot be avoided. To further minimize tissue damage in the donor site, the use of a surgical robotic system for DIEP flap harvest with a totally extraperitoneal approach has been suggested. This totally extraperitoneal approach has a long learning curve because of the narrow preperitoneal space and the difficulty of converting a potential space to an actual space. Thus, the authors suggest a single-port robotic system optimized for narrow surgical spaces as a feasible option for DIEP flap harvest by a totally extraperitoneal approach, which has a shorter learning curve.

A 45-degree Upward Tension-Releasing Epicanthoplasty Performed in 712 Consecutive Cases.

BACKGROUND: Medial epicanthoplasty is commonly used to enhance the aesthetic outcomes of double-eyelid operations in Asia. However, epicanthoplasty can cause problems such as scarring and excessive exposure of the lacrimal lakes. OBJECTIVES: To resolve the problems associated with epicanthoplasty and to create more natural and long-lasting double-eyelid fold lines while minimizing incisions, we performed a 45-degree upward tension-releasing epicanthoplasty. MATERIALS AND METHODS: A total of 712 patients underwent 45-degree upward tension-releasing epicanthoplasty, with or without double eyelidplasty. A triangular skin flap was elevated at a 45-degree angle from the epicanthal fold. The surrounding area was dissected to eliminate the rigid connective tissue between the orbicularis muscle and the skin, which creates skin tension. The incisions were sutured, and a small incision toward the medial canthus was added to further decrease tension and create space for the triangular flap to be transposed. RESULTS: A total of 707 patients underwent 45-degree upward tension-releasing epicanthoplasty with the double-eyelid procedure, and 5 patients underwent 45-degree upward tension-releasing epicanthoplasty alone. No complications were observed for any patients, and 95% of patients were satisfied with this technique. CONCLUSIONS: The 45-degree upward tension-releasing epicanthoplasty can release the tension in the epicanthal fold, minimize scarring, and control lacrimal lake exposure. In particular, this method was effective for creating an in-out double-fold line starting from the epicanthus and for maintaining the double-eyelid line, which can reduce unnecessary incisional double-eyelid surgery.

Anterolateral thigh free flaps and radial forearm free flaps in head and neck reconstruction: A 20-year analysis from a single institution.

BACKGROUND: Reconstruction after removal of a malignant tumor in the head and neck region is crucial for restoring tissue integrity, function, and aesthetics. We retrospectively analyzed patients who underwent intraoral reconstruction surgery using radial forearm free flaps (RFFF) and anterolateral thigh free flaps (ALT) at a single institution to provide more information supporting the choice of a reconstruction method after removal of head and neck cancer. METHODS: The charts of 708 patients who underwent head and neck reconstruction between 1998 and 2018 at the Department of Plastic and Reconstructive Surgery at our institution were retrospectively reviewed. Patients' age, sex, and history of radiation therapy, diabetes mellitus, and smoking were retrieved. The primary cancer site, types of defects, and complications were investigated. RESULTS: Overall, 473 and 95 patients underwent reconstruction surgery with RFFF and ALT, respectively. RFFF was more often used in patients with cancers of the pharynx, larynx, esophagus, or tonsil, while ALT was more frequently used in patients with cancers of the mouth floor with tonsil or tongue involvement. The proportion of patients undergoing ALT increased gradually. Flap failure and donor site morbidities did not show significant differences between the two groups. CONCLUSIONS: RFFF and ALT flaps resulted in similar outcomes in terms of flap survival and donor site morbidity. ALT can be an option for head and neck reconstruction surgery in patients with large and complex defects or for young patients who want to hide their donor site scars.

Stromal vascular fraction injection to treat intractable radiation-induced rectovaginal fistula.

Rectovaginal fistula, which can arise after an injury to the vaginal canal or rectum, is a troublesome obstacle for patients' everyday life. In most cases, it can be covered with a local flap, but previous radiation therapy increases the recurrence rate, making it especially difficult to cure. As the application of stromal vascular fraction (SVF) obtained from enzymatically digested autologous adipose tissue has become increasingly common, several reports have advocated its effectiveness for the treatment of refractory wounds. In light of the angiogenic, regenerative characteristics of SVF, it was incorporated as a treatment option in two cases of rectovaginal fistula discussed here. As described in this report, irradiated rectovaginal fistulas in rectal cancer patients were successfully treated with SVF injection, and we suggest SVF as a feasible treatment option for cases of rectovaginal fistula that would otherwise be very difficult to cure.

Hypofractionated Radiotherapy With Volumetric Modulated Arc Therapy Decreases Postoperative Complications in Prosthetic Breast Reconstructions: A Clinicopathologic Study.

BACKGROUND: Emerging radiation technologies are expected to provide a positive impact on the reduction in postoperative complications in patients receiving prosthetic breast reconstruction. This study aimed to determine whether hypofractionated radiation therapy(RT) with volumetric modulated arc therapy(VMAT) is superior to conventional RT in the setting of prosthetic reconstruction. METHODS: From retrospective data collections, postoperative complications were compared for all patients with mastectomy and staged prosthetic reconstruction without RT, with hypofractionation using 40 Gy in 15 fractions with VMAT (Hypo-VMAT) or conventional RT (50 Gy over 5 weeks). After harvesting subpectoral capsules from patients with informed consents, histologic analysis including immunohistochemistry and immunofluorescence for collagen type I, α-smooth muscle actin, CD34 and CD31 expression was performed. RESULTS: A total of 288 reconstructions without RT, 55 reconstructions with Hypo-VMAT, and 29 reconstructions with conventional RT were examined. During average follow-up period of 34.8 months, rates of overall complications were 6.3% in the no-radiation group, 18.2% in Hypo-VMAT group and 44.8% in conventional-RT group with significant differences (no-RT vs Hypo-VMAT: p=0.006; Hypo-VMAT vs conventional-RT: p=0.012). Levels of myofibroblasts and tissue fibrosis were lower in the Hypo-VMAT group than in conventional-RT group (p=0.016 and p=0.040, respectively), while those of progenitor cells and microvessel density were higher in the Hypo-VMAT group than in conventional-RT group (p<0.001 and p<0.001, respectively). CONCLUSION: We demonstrated that hypofractionated RT with VMAT served to reduce radiation-related morbidities in prosthetic reconstruction from a clinicopathologic perspective, compared to conventional RT. It may offer a practical strategy to mitigate radiation-related complications in clinical settings.

Staged reconstruction of a chronically infected large skull defect using free tissue transfer and a patient-specific polyetheretherketone implant.

Reconstructions of extensive composite scalp and cranial defects are challenging due to high incidence of postoperative infection and reconstruction failure. In such cases, cranial reconstruction and vascularized soft tissue coverage are required. However, optimal reconstruction timing and material for cranioplasty are not yet determined. Herein, we present a large skull defect with a chronically infected wound that was not improved by repeated debridement and antibiotic treatment for 3 months. It was successfully treated with anterolateral thigh (ALT) free flap transfer for wound salvage and delayed cranioplasty with a patient-specific polyetheretherketone implant. To reduce infection risk, we performed the cranioplasty 1 year after the infection had resolved. In the meantime, depression of ALT flap at the skull defect site was observed, and the midline shift to the contralateral side was reported in a brain computed tomography (CT) scan, but no evidence of neurologic deterioration was found. After the surgery, sufficient cerebral expansion without noticeable dead-space was confirmed in a follow-up CT scan, and there was no complication over the 1-year follow-up period.

Inhibition of Wnt signaling pathway suppresses radiation-induced dermal fibrosis.

Progressive fibrosis of the dermal tissues is a challenging complication of radiotherapy whose underlying mechanism is not fully understood, and there are few available treatments. The canonical Wnt/ß-catenin signaling pathway plays an important role in fibrosis as well as in the epithelial-to-mesenchymal transition (EMT). We investigated whether inhibition of Wnt/ß-catenin signaling with sLRP6E1E2, a molecule that binds to extracellular Wnt ligands, ameliorated radiation-induced fibrosis both in vitro and in vivo. Radiation with a single dose of 2 Gy not only facilitated fibrosis in cultured human dermal fibroblasts via activation of the Wnt/ß-catenin pathway but also initiated EMT in cultured keratinocytes, developing collagen-producing mesenchymal cells. sLRP6E1E2-expressing adenovirus treatment exerted anti-fibrotic activity in irradiated cultured dermal fibroblasts and keratinocytes. In a mouse model, a single fraction of 15 Gy was delivered to the dorsal skins of 36 mice randomized into three groups: those receiving PBS, those receiving control adenovirus, and those receiving decoy Wnt receptor-expressing adenovirus (dE1-k35/sLRP6E1E2). The mice were observed for 16 weeks, and excessive deposition of type I collagen was suppressed by sLRP6E1E2-expressing adenovirus treatment. These results demonstrate that the modulation of the Wnt/ß-catenin pathway has the potential to decrease the severity of radiation-induced dermal fibrosis.

Author Correction: Robot-assisted Nipple-sparing Mastectomy with Immediate Breast Reconstruction: An Initial Experience.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Huge Anterior Skull Base Defect Reconstruction on Communicating Between Cranium and Nasal Cavity: Combination Flap of Galeal Flap and Reverse Temporalis Flap.

INTRODUCTION: Traditionally, galeal flap or cranialization was often used to reconstruct the skull base defect caused by trauma or tumor removal. However, in the case of huge skull base defect, galeal flap is not enough to block the communication between nasal cavity and intracranial space. In this study, authors suggest combination flap of galea and reverse temporalis muscle as a method for reconstruction of huge skull base defect. MATERIALS AND METHODS: From 2016 to 2019, retrospective review was conducted, assessing 7 patients with bone defect which is not just opening of frontal sinus but extends to frontal sinus and cribriform plate. Reconstructions were done by combination of galeal flap and reverse temporalis muscle flap transposition. RESULTS: Defects were caused by nasal cavity tumor with intracranial extension or brain tumor with nasal cavity extension. There was no major complication in every case. During the follow up period, no patient had signs of complication such as ascending infection, herniation and CSF rhinorrhea. Postoperative radiologic images of all patients that were taken at least 6 months after the surgery showed that flaps maintained the lining and the volume well. DISCUSSION: Conventional reconstruction of skull base defect with galeal flap is not effective enough to cover the large sized defect. In conclusion, galeal flap in combination with reverse temporalis muscle flap can effectively block the communication of nasal cavity and intracranium.