Patient-reported outcomes in bilateral prophylactic mastectomy with breast reconstruction: A narrative review.

In women at high risk of developing breast cancer, bilateral prophylactic mastectomy (BPM) 1 significantly reduces the risk; simultaneously, breast reconstruction preserves body integrity. Given the complex and personal nature of such surgical procedures, patient assessment of satisfaction and health-related quality of life (HRQoL) 2 is essential in evaluation of surgical outcomes. With this review, we aim to organize the current knowledge on patient-reported outcomes (PROs) 3 in bilateral prophylactic surgery. Literature search was conducted using the databases Google Scholar, PubMed, and Web of Science to address the following questions, which can help clinicians and women undergoing the procedures navigate their healthcare decision-making process: How does BPM with reconstruction influence cancer-related distress? How does the surgery impact patient satisfaction and HRQoL? How do preoperative PROs differ from postoperative outcomes? Does the type of BPM and the type of reconstruction impact patient satisfaction and HRQoL? Furthermore, we summarize available patient-reported outcome measures (PROMs) 4 that can be administered to women undergoing BPM with reconstruction. In addition, we discuss possible future directions for PRO research in prophylactic breast surgery.

Anterior transposition of the radial nerve to achieve primary suture for its reconstruction: Anatomical feasibility study.

INTRODUCTION: Radial nerve palsy after humeral shaft fractures is often associated with formation of a neuroma in continuity. The current standard of treatment is neuroma resection and nerve grafting with contentious results. Anterior transposition of the radial nerve may reduce the length of its path, allowing reconstruction by primary suture. The aim of this study was to determine the maximum length of radial nerve defect that can be treated by the anterior transposition to allow primary suture to be performed. METHODS: We use 10 arms from five fresh cadavers. The radial nerve was dissected in the lateral inter-muscular septum and along the anterior aspect of the forearm. The radial nerve was transected at the level of the spiral groove and both stumps were than transposed anterior to the medial inter-muscular septum. The length of tension-free overlap that could be achieved was measured. RESULTS: The average length of the overlap at zero degrees of elbow flexion was 10.00 ± 1.84 mm. Theoretically, this will allow a defect of 20 ± 3.69 mm SD to be treated by primary suture. CONCLUSION: Our results suggest that anterior transposition can be used for radial nerve defects up to 2 cm; however, dissection of both stumps proved to be challenging.

Novel Patient-Reported Outcome Measures for the Assessment of Patient Satisfaction and Health-Related Quality of Life Following Postmastectomy Breast Reconstruction.

BACKGROUND: Patient-reported outcome measures (PROMs) have become an integral part of the evaluation of reconstruction surgery outcomes. However, there are limitations in current PROMs when it comes to the assessment of well-being during inpatient stay, patient perception of health, relationship with partner, and vitality (i.e., mood and ability to work and pursue hobbies, carry out daily tasks, and sleep) following breast reconstructive surgery. The aim was to develop a novel set of measures to compare patient satisfaction and health-related quality of life following different types of postmastectomy breast reconstruction. METHODS: A novel questionnaire was created and refined through cognitive interviews with patients and expert feedback. A field test study was conducted, including patients who had undergone delayed postmastectomy breast reconstruction with implant, autologous tissue, or combination of implant and autologous tissue. Based on the results, confirmatory factor analysis and examination of reliability of the questionnaire were conducted. Results of patient responses were analyzed using Chi-square test, Kruskal-Wallis test, and Mann-Whitney U test. RESULTS: Confirmatory factor analysis showed good model fit, and Cronbach's alpha indicated high internal consistency of the questionnaire. Besides that, patients with combination reconstruction reported significantly lower vitality than patients with implant and autologous reconstruction (p = 0.048). CONCLUSIONS: This novel questionnaire expands the current knowledge base of postmastectomy breast reconstruction PROMs. Results of the field test study showed that combination reconstruction was associated with lower patient vitality than other reconstruction types. LEVEL OF EVIDENCE IV: 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 .

Risk Comparison Using Autologous Dermal Flap and Absorbable Breast Mesh on Patient Undergoing Subcutaneous Mastectomy with Immediate Breast Reconstruction.

In patients with large breasts undergoing a subcutaneous mastectomy with immediate implant-based reconstruction, is necessary to perform a mastopexy. The combination of these procedures increases the complication rate. To reduce it, it is necessary to cover the lower pole of the implant. Our study aimed to compare the use of an autologous dermal flap and an absorbable breast mesh. A total of 64 patients without previous breast surgery were divided into 2 groups, each with 32 patients. In the 1st group, the implant was covered with an autologous caudally based dermal flap, sutured to the great pectoral muscle. In the 2nd group, the implant was covered with a fully absorbable breast mesh, fixed caudally in the inframammary fold and cranially to the great pectoral muscle. The incidence of complications, the aesthetic effect, and patient satisfaction were evaluated in a one-year follow-up. In the 1st group, there were 2 cases of seroma, 2 partial nipple-areola complex necrosis, 4 cases of dehiscence in the T-suture, and the malposition of the implant in 2 patients. In the 2nd group, there were 2 cases of seroma, 2 cases of T-junction dehiscence, and 1 case of full nipple-areola complex necrosis, which resulted in implant loss. There was no significant difference in patient satisfaction between the study groups. The dermal flap is more suitable for breasts with pronounced ptosis. The use of the synthetic mesh is suitable for smaller breasts, where the possible dermal flap would be too small to cover the implant. LEVEL OF EVIDENCE IV: 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 .

Evaluation of the Number of Follow-up Surgical Procedures and Time Required for Delayed Breast Reconstruction by Clinical Risk Factors, Type of Oncological Therapy, and Reconstruction Approach.

BACKGROUND: Breast reconstructive surgery is often a multistage process. The aim was to understand which factors might increase the number of follow-up surgeries and the length of time required to complete the reconstruction process. METHODS: A cross-sectional analysis was performed. Clinical data of 110 patients who underwent delayed postmastectomy breast reconstruction with a 5-year examination period were reviewed retrospectively. Impact of clinical risk factors, oncological therapy, and reconstruction approach on the number of surgeries and the length of required time was analyzed. Mann-Whitney U test and Kruskal-Wallis rank sum test were used. RESULTS: In patients undergoing perioperative hormone therapy, an average of 2.9 surgeries and length of 20.2 months were required compared to 2.3 surgeries and 14.0 months in patients without hormone therapy (P = 0.003; P = 0.005). Previous abdominal surgery was associated with an increased number of breast reconstruction stages of 3.1 per patient (P = 0.056) and a longer reconstruction time of 23.0 months (P = 0.050). Patients undergoing nipple reconstruction or implant revision required an increased number of surgeries (P < 0.001; P = 0.012) and a longer reconstruction time (P = 0.002; P < 0.001). Contralateral breast surgery and flap revision were associated only with an increased number of surgeries (P < 0.001; P < 0.001). CONCLUSION: Perioperative hormone therapy was associated with a significantly higher number of surgeries and duration of time required to complete the reconstruction process. The highest increase in the number of surgeries was in patients with flap revision including anastomosis revision and necrectomy. LEVEL OF EVIDENCE IV: 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 .

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part II: Clinical application.

Despite the high success rate of micro-vascular flaps, anastomosis compromise occurs in 5-10% and that can lead to flap failure. Reliable monitoring of the flap is therefore of similar importance to that of the precise surgical procedure itself. Multiple methods have been reported for monitoring of the flap vitality, the first one being direct visual monitoring. In buried flaps direct visualisation is not feasible or is unreliable. In these cases we can extend the buried flap to expose a segment of it to act as a monitoring sentinel. For the purpose of this review we used our clinical experience as a starting point, and for the extended information and expertise we conducted a search of the PubMed database. Over 40 monitoring techniques have been reported to-date. Direct visual monitoring is still generally used method with a reliability of up to 100% and an overall success rate of up to 99%. Direct visualisation remains as the simplest, cheapest and yet a very reliable method of flap monitoring. In this review we provide a description of various possible techniques for externalising part of a buried flap, define the tissues that can be used for this purpose and we summarise the procedures that should be followed to achieve the best reliability and validity of monitoring the skin island.

Patient-Reported Outcomes of Three Different Types of Breast Reconstruction with Correlation to the Clinical Data 5 Years Postoperatively.

BACKGROUND: The aim of this study was to compare long-term clinical and patient-reported outcomes in terms of satisfaction and health-related quality of life (HRQoL) following postmastectomy breast reconstruction using BREAST-Q in patients undergoing implant-based reconstruction, abdominal-based autologous reconstruction, and combined reconstruction (with implant and LD flap or implant and TDAP flap). METHODS: A cross-sectional study was conducted. Patients had undergone delayed postmastectomy breast reconstruction and completed the BREAST-Q reconstruction module. The results were related to the clinical data obtained from the clinic's patient record system. A 5-year examination was included. Mean scores and standard deviations were calculated. Kruskal-Wallis test, Chi-square goodness of fit test and Chi-square test were used for the statistical analysis. RESULTS: Overall, 110 patients (n = 24 implant, n = 38 autologous, n = 48 combination) were included. Patients with autologous reconstruction reported greater postoperative satisfaction with breasts (p < 0.001), satisfaction with outcome (p < 0.001), psychosocial well-being (p = 0.001), and sexual well-being (p = 0.051). CONCLUSION: This study represents a comprehensive long-term examination of postmastectomy breast reconstruction. Autologous reconstruction patients had higher postoperative satisfaction and HRQoL than patients receiving other types of reconstruction despite having more intense oncological therapy and the highest mean number of follow-up surgical procedures. 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 .

Dentoalveolar Arch Dimensions in UCLP Boys After Neonatal Cheiloplasty or After Lip Surgery at the Age of 3 or 6 Months.

OBJECTIVE: To compare the influence of 3 different time protocols of cleft lip and palate operations on the growth of the dentoalveolar arch in patients with unilateral cleft lip and palate (UCLP). MATERIALS AND METHODS: We evaluated 64 plaster casts of 8-year-old boys with UCLP operated on according to 3 different time protocols: lip repair at the age of 6 months and palate repair at 4 years, lip repair at 3 months and palate repair at 9 months, and neonatal lip repair and palate repair at 9 months. The control group contained 13 plaster casts of 8-year-old boys. The dentoalveolar arch width was measured between deciduous canines and between the second deciduous molars; the length was measured between incisive papilla and the line connecting both tuber maxillae. RESULTS: All measured distances were statistically significantly smaller in boys with UCLP than in the control group. Intercanine width was not statistically significantly different between the patients operated on according to the different time protocols. In comparison to the lip repair at 6 months and palate repair at 4 years, the intermolar width was statistically significantly smaller in the group with neonatal lip repair; the alveolar arch length was statistically significantly shorter in both groups with lip repair performed neonatally or at 3 months. CONCLUSIONS: The length of the dentoalveolar arch is shorter after surgical repair of cleft lip neonatally or at the age of 3 months. Cleft palate repair at 9 months can contribute to a reduction in the width of the dentoalveolar arch.

Abdominal wall allotransplantation.

Allotransplantation of vascularized composite tissue is a new field of transplantation surgery. One application of this technique is abdominal wall transplantation used as a supplementary procedure to the transplantation of visceral organs in patients with abdominal compartment deficits. As abdominal wall closure problems are experienced in around 30-40% of such patients, peer reviewed conclusions on the viability of various options, are important for an informed choice of possible procedures. This review focuses on the abdominal wall allotransplantion procedure. Our search provided 35 appropriate references which we used to support our findings as follows: abdominal wall transplantation was performed in 33 patients at seven centres. Of these, 30 had a full thickness abdominal wall transplanted from the same donor, 3 from a second donor. Three had visceral organ transplants and in addition, the posterior sheet of the rectus muscle fascia. In summary, our findings were that abdominal wall allotransplantation does not jeopardize the outcome of visceral organs transplantation. There is no higher risk of complications or rejection of the visceral organs. There have been no fatalities as a direct result of complications due to abdominal wall transplantation. Finally, the transplanted abdominal wall may provide an early warning of rejection before diagnostic tests on the bowel are symptomatic.

Anaplastic Large-Cell Lymphoma Associated with Breast Implants: A Case Report of a Transgender Female.

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare peripheral T cell lymphoma. BIA-ALCL is a disease of the fibrous capsule surrounding the implant and occurs in patients after both breast reconstruction and augmentation. More than 300 cases have been reported so far, including two in a transgender patient. Here we describe BIA-ALCL presented with a mass in a transgender patient and the first case of BIA-ALCL in the Czech Republic. In 2007, a 33-year-old transgender male to female underwent bilateral breast augmentation as a part of his transformation to female. In June 2014, the patient developed a 5-cm tumorous mass in her left breast. Magnetic resonance imaging of the chest revealed a ruptured implant and a tumorous mass penetrating into the capsule and infiltrating the pectoral muscle. An R0 surgery was indicated-the implant, silicone gel and capsule were removed, and the tumorous mass was resected together with a part of the pectoral muscle. Histology revealed anaplastic large-cell lymphoma. The patient underwent standard staging procedures for lymphoma including a bone marrow trephine biopsy, which confirmed stage IE. The patient was treated with the standard chemotherapy for systemic ALCL-6 cycles of CHOP-21. The patient was tumor-free at the 2-year follow-up. BIA-ALCL has been reported mostly in women who received implants for either reconstructive or aesthetic augmentation. This is the third report of BIA-ALCL in a transgender person, the first in the Czech Republic. Level of Evidence V 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 .

Comparison of Patient-reported Outcomes after Implant Versus Autologous Tissue Breast Reconstruction Using the BREAST-Q.

BACKGROUND: The demand for reconstructive breast procedures of various types has accelerated in recent years. Coupled with increased patient expectations, it has fostered the development of oncoplastic and reconstructive techniques in breast surgery. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life are the most significant outcome variables when evaluating surgical success. The aim of this study was to evaluate the quality of life after implant breast reconstruction compared with autologous breast reconstruction. MATERIALS AND METHODS: A cross-sectional study design was used. A total of 65 women who had completed postmastectomy implant-based or autologous reconstruction in the participating center were asked to complete the BREAST-Q (Reconstruction Module). RESULTS: Data analysis demonstrated that women with autologous breast reconstruction were significantly more satisfied with their breasts (P = 0.0003) and with the overall outcome (P = 0.0001) compared with women with implant breast reconstruction. All other BREAST-Q parameters that were considered and observed were not significantly different between the 2 patient groups. CONCLUSIONS: Through statistical analysis, our results showed that patients who underwent autologous tissue reconstruction had better satisfaction with the reconstructed breast and the outcome, while both techniques appear to equally improve psychosocial well-being, sexual well-being, and chest satisfaction.

Centrifugation versus PureGraft for fatgrafting to the breast after breast-conserving therapy.

BACKGROUND: Breast-conserving treatment (BCT) leads to a progressive and deteriorating breast deformity. Fatgrafting is ideal for breast reconstruction after BCT. The most frequently utilized technique for fat processing is centrifugation. The PureGraft device (Cytori Therapeutics, San Diego, CA, USA) is a new method that involves washing and filtering the fat to prepare the graft. We compared the subjective and objective outcomes of two fat-processing methods, centrifugation and PureGraft filtration. METHODS: Thirty patients underwent breast reconstruction performed by a single surgeon (OM) after BCT in our department between April 2011 and September 2012. The patients were preoperatively divided into two groups randomly: 15 received fatgrafts processed by centrifugation, and 15 received fatgrafts processed by washing in PureGraft bags. The patients were followed up for 12 to 30 months. To measure the subjective outcome, we distributed the BREAST-Q questionnaire to all the patients both preoperatively and 1 year postoperatively. The BCCT.core software evaluated the objective outcome of breast reconstruction by fatgrafting. RESULTS: The Breast-Q results indicated a tremendous improvement in the modules "Satisfaction with Breast" and "Psychosocial Well-being". The "Sexual Well-being" scale also improved. Only the module "Satisfaction with Breasts" significantly differed between groups; patients treated with the PureGraft fat exhibited better outcomes. The BCCT.core results did not significantly differ between the groups. CONCLUSION: One year postoperatively, the outcomes of the use of PureGraft bags or centrifugation to process fat for breast reconstruction after BCT did not differ. The unpredictability of the results following fatgrafting procedures is likely due to interindividual differences with yet-undisclosed causes.

Mesenchymal stem cells seeded on cross-linked and noncross-linked acellular porcine dermal scaffolds for long-term full-thickness hernia repair in a small animal model.

Biological meshes are biomaterials consisting of extracellular matrix that are used in surgery particularly for hernia treatment, thoracic wall reconstruction, or silicone implant-based breast reconstruction. We hypothesized that combination of extracellular matrices with autologous mesenchymal stem cells used for hernia repair would result in increased vascularization and increased strength of incorporation. We cultured autologous adipose-derived stem cells harvested from the inguinal region of Wistar rats on cross-linked and noncross-linked porcine extracellular matrices. In 24 Wistar rats, a standardized 2×4 cm fascial defect was created and repaired with either cross-linked or noncross-linked grafts enriched with stem cells. Non-MSC-enriched grafts were used as controls. The rats were sacrificed at 3 months of age. The specimens were examined for the strength of incorporation, vascularization, cell invasion, foreign body reaction, and capsule formation. Both materials showed cellular ingrowth and neovascularization. Comparison of both tested groups with the controls showed no significant differences in the capsule thickness, foreign body reaction, cellularization, or vascularization. The strength of incorporation of the stem cell-enriched cross-linked extracellular matrix specimens was higher than in acellular specimens, but this result was statistically nonsignificant. In the noncross-linked extracellular matrix, the strength of incorporation was significantly higher in the stem cell group than in the acellular group. Seeding of biological meshes with stem cells does not significantly contribute to their increased vascularization. In cross-linked materials, it does not ensure increased strength of incorporation, in contrast to noncross-linked materials. Owing to the fact that isolation and seeding of stem cells is a very complex procedure, we do not see sufficient benefits for its use in the clinical setting.

Breast Reconstruction after a Bilateral Mastectomy Using the BRAVA Expansion System and Fat Grafting.

SUMMARY: Fat graft breast reconstruction following a mastectomy is always limited by the size of the skin envelope, which affects the amount of graft that can be injected in 1 session. Because the fat graft naturally resorbs in all patients, several sessions of fat grafting are necessary. BRAVA's negative pressure causes a "reverse" expansion of the skin envelope, thus permitting more space for the fat graft. This allows decreasing number of required procedures for an adequate breast reconstruction. We operated on a 38-year-old patient 4 years after bilateral mastectomy without irradiation for breast cancer. Before the procedure, the patient was instructed to wear the BRAVA system for 12 hours daily for 2 months before the first session, at all times between the sessions and for 1 month following the last fat grafting session. We performed 3 fat grafting sessions, as planned. Altogether, we injected 840 cm(3) of fat on the right side and 790 cm(3) of fat on the left side. Four months after the last operation, the patient was very satisfied with her new breasts. The breasts were soft, with good sensation and a natural feel. Using the BRAVA external expansion system for the enhancement of fat grafting is a suitable technique for breast reconstruction after a mastectomy. This technique produces soft and natural feeling breasts in fewer operative sessions, with a minimal risk of complications. Patient compliance, however, is greatly needed to achieve the desired results.

Evaluation of the long-term stability of sheath plication using absorbable sutures in 51 patients with diastasis of the recti muscles: an ultrasonographic study.

BACKGROUND: Rectus sheath plication within abdominoplasty is a standard treatment for diastasis of the recti muscles. There are questions regarding the efficacy and long-term stability of the correction of rectus diastasis and whether absorbable sutures work as well as nonabsorbable sutures. METHODS: The authors conducted a case-control study to assess the outcomes of recti muscle diastasis correction with absorbable suture. The authors assessed the outcomes by physical and ultrasonographic examinations and a patient questionnaire, which asked about the number of pregnancies and the types of deliveries, other abdominal operations before or after the abdominoplasty, and the interval of time required to return to full activity. During the examination, the interrecti distances were measured at three levels: halfway between the xiphoid and umbilicus, just above the umbilicus, and halfway between the umbilicus and the pubis. The same examination was performed on a control group of nulliparous women. RESULTS: The authors examined a group of 51 patients aged 25 to 64 years (mean, 41 years). The time interval between the operation and the ultrasonographic examination was 12 to 41 months (mean, 20.8 months). There was no statistically significant difference between the studied group and the control group with respect to their interrecti distances. CONCLUSION: Rectus sheath plication using absorbable sutures in patients with diastasis of the recti muscles is a reliable method that maintains the long-term stability of the abdominal wall. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Unusual regression of severe recurrent lymphatic malformation of a face after contraception and pregnancy.

We report the case of a female who had suffered from progressive lymphatic malformation in the orbito-temporal region since childhood. Many surgical interventions were performed, including radical excision and shunt drainage. Despite aggressive surgical treatment, recurrence was observed after every intervention. Eventually, the condition regressed after the patient began taking a contraceptive. Moreover, it virtually disappeared after pregnancy.

Use of deepithelialized flap in mammoplasties: simple method with excellent results.

BACKGROUND: A deepithelialized flap is used in almost all surgical fields, particularly in plastic, reconstructive, and aesthetic surgery. This article describes several operating techniques using deepithelialized flaps that in specific cases can improve silicone breast implant coverage. METHODS: All the patients underwent surgery in our department. The operations described are subcutaneous mastectomies with immediate reconstruction using silicone implants, mastopexy with immediate augmentation using silicone implants in a patient with very thin skin, and reaugmentation with mastopexy and reimplantation of silicone implants in a patient with very thin skin and extremely thin pectoral muscles. In all the described operations, we used a superolaterally based deepithelialized flap from the lower part of the breast that we fixed to the thoracic wall to cover the inferior part of the implant. RESULTS: The authors have extensive experience using this flap in such specific cases. To date, they have performed more than 30 operations using this technique. Each patient was followed for 2-7 years, and the findings show excellent postoperative results. None of the patients had implant extrusions, flap extrusions, or infections. The long-term cosmetic results were outstanding. CONCLUSION: The use of deepithelialized flaps in patients with very thin skin or pectoral muscles is a safe and easy way to improve implant coverage and prevent implant extrusion. This technique provides an alternative surgical option that can be beneficial in certain mammary cases.

Moustache reconstruction in patients with cleft lip: (final aesthetic touches in clefts-part ii).

Men with clefts often have limited or even missing moustache growth in scar areas or in the upper lip prolabium. However the histological testing showed the absence or at least the inactive form of androgenic receptor in hair follicle of cleft site, transplantation of autologous grafts harvested from hair was successful in all six cases either into scars or the prolabium. A more natural effect was achieved by using micrografts. The positive reaction of patients proved there is a need for detailed treatment in highly outgoing individuals.