Oncoplastic breast surgery: Achieving oncological and aesthetic outcomes.

BACKGROUND AND OBJECTIVES: Oncoplastic reconstruction allows more patients to become candidates for breast-conserving surgery (BCS). Oncologic resection of a breast lesion is combined with plastic surgical techniques to improve aesthetic results. Choosing the best oncoplastic method is essential to optimize outcomes, improve cosmesis, and minimize postoperative complications. The aim of this study is to present a treatment algorithm incorporating oncoplastic techniques based on diagnosis, tumor size, tumor location, and breast size and shape. METHODS: A retrospective pilot study of a prospectively collected database was conducted in patients undergoing immediate oncoplastic surgery from 2010 to 2015 at our institution. Oncoplastic surgical techniques were defined as complex layered closure, local tissue rearrangement, pedicled flap, mastopexy, bilateral reduction, or implant placement. Clinical, demographic, and histopathologic data were extracted from electronic patient records. Patient satisfaction was measured by the BREAST-Q questionnaire. RESULTS: A total of 42 women and 46 breasts were included. An algorithm was formulated to assist in selecting an optimal oncoplastic reconstruction plan after BCS. Additionally, patient satisfaction with good aesthetic results was reported. CONCLUSION: In this study, the authors present a reconstructive algorithm describing various oncoplastic approaches aimed to provide a guideline in clinical practice when employing oncoplastic surgery.

Delayed hypersensitivity reaction to acellular dermal matrix in breast reconstruction: the red breast syndrome?

BACKGROUND: Acellular dermal matrix (ADM) has become a valuable tool in reconstructive breast surgery, in part because it has been considered to be a non-reactive and non-immunogenic entity. However, some patients who undergo breast reconstruction with ADMs develop postoperative erythema overlying their ADM grafts. The etiology of this phenomenon is poorly understood. METHODS: In this article, we summarize clinical cases in which patients developed localized breast erythema following reconstruction with ADMs. We review what is known about postoperative breast erythema after ADM-based breast reconstructions and the possible antigenicity of biologic mesh implants. RESULTS: We report 4 implant-based breast reconstruction patients who developed erythematous reactions overlying the region where ADM was placed: one demonstrated a delayed-type hypersensitivity reaction on punch biopsy of the affected skin, leading to removal of the biologic product; 2 others had a similar clinical presentation that responded to corticosteroids without removal of the biologic material, with 1 patient experiencing recrudescence of erythema that responded fully to a second course of corticosteroids; and a fourth showed erythema that was only moderately responsive to antibiotic therapy but which improved consistently after the patient initiated chemotherapy. CONCLUSION: We propose that the etiology of erythema overlying ADM grafts, and the so-called red breast syndrome, may in some patients be a delayed-type hypersensitivity reaction to the ADM product. Affected patients may benefit from treatment with corticosteroids or similar medications, and that such treatment may, in some cases, enable patients to retain the ADM grafts and enable salvage of the reconstructed breast.

Outpatient Prosthetic-Based Reconstruction during COVID-19 Pandemic Possible in Selected Patients without Increased Complications.

BACKGROUND: Following the reopening of elective surgery, the authors' division transitioned from inpatient admission to same-day discharge for immediate prosthetic breast reconstruction in an effort to decrease the hospital's clinical burden and minimize potential coronavirus disease of 2019 exposure. This study aims to compare complication rates following this acute transition for patients who had inpatient and outpatient mastectomy with immediate alloplastic reconstruction. METHODS: A retrospective chart review was performed on patients who underwent mastectomy with immediate prosthetic reconstruction. The outcome of interest was 30-day morbidity. Descriptive statistics were compared for patients with outpatient and inpatient operations. Odds ratios were calculated to determine whether any preoperative factors increased odds of 30-day complications. RESULTS: A total of 115 patients were included in this study. Twenty-six patients had outpatient surgery and 89 stayed inpatient postoperatively. Same-day discharge did not significantly impact the odds of having one or more 30-day complications (OR, 0.275; 95% CI, 0.047 to 1.618; P = 0.153). Patients with complications had significantly longer median operating times [5.0 hours (interquartile range, 4.0 to 6.0 hours) versus 4.0 hours (interquartile range, 3.0 to 5.0 hours; P = 0.05), and there was a statistically significant association between length of surgery and odds of complication (OR, 1.596; 95% CI, 1.039 to 2.451; P = 0.033). Age was independently associated with increased risk of 30-day complication (OR, 1.062; 95% CI, 1.010 to 1.117; P = 0.020). CONCLUSION: The authors' findings support a continuation of same-day discharge strategy, which could decrease costs for patients and hospitals without increasing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Technique of Abdominal Wall Tissue Expansion for the Treatment of Massive Complicated Ventral Hernias.

Abdominal wall tissue expansion is a unique technique that seeks to augment and expand both the fascial and subcutaneous tissues/skin layers to achieve durable closure of otherwise challenging ventral hernias. In addition to allowing primary fascial closure in a majority of cases, this technique enables reduced tension on the closure, potentially decreasing the recurrence rate. This article describes the senior author's surgical technique for abdominal wall tissue expansion in massive complicated ventral hernias. The plastic surgeon is at a unique advantage to assist with the repair of massive complicated ventral hernias given their comfort with complex tissue handling and expandable devices. This specialized technique thus provides an opportunity for plastic surgeons to serve as expert co-surgeons with general surgery colleagues to help achieve superior outcomes in patients with these challenging hernias.

Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation.

The purpose of this study is to describe our experience with nipple-sparing mastectomy and immediate reconstruction, with particular attention to patient satisfaction, aesthetic results, and nipple sensation. Immediate reconstruction was performed on 17 breasts in 10 patients, using either implants or autologous tissue flaps. Assessment of outcomes was performed through patient interviews, a self-reported patient satisfaction survey and review of postoperative photographs. Short-term complications included partial loss of the nipple-areolar complex requiring debridement (n = 3) and removal of the nipple-areolar complex (n = 2) for occult ductal carcinoma in situ. While all patients with completed breast reconstructions were satisfied with their general reconstructive experience, 6 of 9 patients were aesthetically satisfied with their breast reconstruction. Postoperative nipple sensation was reported in 75% of patients, although sensation was low (mean of 2.8 of 10). As nipple-sparing mastectomy is becoming an increasing patient preference, preoperative discussion needs to address expectations, aesthetic satisfaction, and long-term cancer control.

Eliminating the vertical scar in breast reduction-Boston modification of the Robertson technique.

BACKGROUND: Surgeons often advise patients with large ptotic breasts to undergo a Wise pattern reduction (WPR) mammaplasty using an inferior pedicle technique with consideration of a free-nipple graft. OBJECTIVE: We describe the Boston modification of the Robertson technique (BMRT), which allows for the elimination of the vertical scar using a low horizontal scar mammaplasty with a broad central-inferior pedicle. METHODS: We retrospectively reviewed the surgical characteristics of 239 patients who underwent mammaplasty using the BMRT technique (n = 145) and compared these with patients undergoing WPR (n = 94). Patients were eligible for BMRT if they had a minimum of 5 cm between the lower aspect of the new areola and superior aspect of the old areola. RESULTS: The BMRT patients were more obese than the WPR patients (BMI 32.4 +/- 6 kg/m(2) vs 28.0 +/- 5 kg/m(2)) and also were more ptotic. The average distance from the suprasternal notch to the nipple was (36.5 +/- 5 cm vs 30.1 +/- 3 cm). For bilateral reductions, the average combined weight removed was 1240 g for BMRT, and 700 g for WPR. The BMRT unilateral reductions also had more tissue removed than unilateral WPRs (980 g vs 465 g). Rates of hematoma formation, minor wound dehiscence, and scar hypertrophy were greater in bilateral WPRs compared to bilateral BMRT mammaplasties. CONCLUSIONS: The BMRT is a safe and reliable method of reduction mammaplasty when there is macromastia and significant ptosis. This technique avoids the vertical scar and hides the transverse scar in the shadow of the inferior breast.

Infectious Complications Leading to Explantation in Implant-Based Breast Reconstruction With AlloDerm.

OBJECTIVE: The role for acellular dermal matrix in implant-based breast reconstruction-providing coverage of the inferolateral border of the underlying prosthesis and allowing control over the inframammary fold-has become increasingly popular. Although AlloDerm (LifeCell, Branchburg, NJ) is free of cellular components responsible for the antigenic response, its processing does not guarantee sterility. In this study, we examine the infectious complications in tissue expander/implant-based reconstruction with AlloDerm. METHODS: A retrospective cohort analysis was completed on 321 implant-based breast reconstructions over a 10-year period (1998-2008) at an academic institution. Of these cases, 75 reconstructions used AlloDerm and 246 reconstructions did not. The incidence of infections that required readmission for intravenous (IV) antibiotics and explantation was determined. Prosthetic explants due to hematoma or patient dissatisfaction were excluded from analysis. RESULTS: There were no differences in rates of readmission for IV antibiotics (2.8% vs 5.3%; P = .291). The rate of explantation due to infected fluid collections and extrusion was higher in the AlloDerm group (8.0%, n = 6) than that in the control group (1.6%, n = 4). This result was statistically significant (P = .013). CONCLUSION: In this study, the rates of IV antibiotic administration for the treatment of cellulitis in implant-based breast reconstructions did not differ because of the presence of AlloDerm; however, the rate of explantation was statistically higher in reconstructions using AlloDerm. This technique has great potential in breast reconstruction, especially for single-staged implant-based reconstruction, but careful counseling of patients with regard to the higher risk of explantation is necessary.

Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques.

BACKGROUND: Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction. METHODS: All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. RESULTS: Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198). CONCLUSIONS: Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Impact of regional referral centers for microsurgical breast reconstruction: the New England perforator flap program experience.

BACKGROUND: Development of new, microsurgical techniques for breast reconstruction has led to more natural and durable reconstruction while minimizing morbidity. Despite these advances, institutions are slow to integrate subspecialized programs because of the additional resources required. In February 2004, our institution developed a microsurgery program for perforator flap breast reconstruction. The purpose of this study is to analyze the impact of this program with attention to reconstruction rates, patient satisfaction, and referral patterns. STUDY DESIGN: A retrospective chart review was performed on all women who had undergone mastectomy or breast reconstruction at our hospital. A total of 1,172 patients were identified between 1999 and 2006. Patients who had breast reconstruction received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. A 75.4% response rate was obtained. RESULTS: Since the program's inception, there has been a significant increase in the immediate reconstruction rate from 51.5% to 63.9% (p < 0.001). Between the two time periods, general patient satisfaction after breast reconstruction increased from 58.5% to 74.4% (p < 0.001), and aesthetic satisfaction increased from 58.5% to 69.9% (p = 0.010). In addition, we have seen a 4.1-fold increase in the number of patients per year from outside institutions for delayed breast reconstruction. CONCLUSIONS: The addition of a perforator flap program for breast reconstruction to accredited cancer centers can increase both patient satisfaction and reconstruction rates. The shift in referral patterns emphasizes the role of breast reconstruction within a regional referral center.

Delayed division of the thoracodorsal nerve: a useful adjunct in breast reconstruction.

Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the routine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidentally injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction.

Salvage treatment of an irradiated, infected lumbosacral wound.

A 60-year-old male with lumbosacral multiple myeloma received 5100 cGy of external-beam radiation, thalidomide, and Decadron. He subsequently underwent excision of the epidural tumor, decompressive L4, L5, and S1 laminectomies, and bilateral L4-5 and L5-S1 medial facetectomies. The patient developed osteoradionecrosis, cerebrospinal fluid leak, wound infection, and sepsis. Debridement and bilateral V-Y fasciocutaneous advancement flaps failed. Pedicled omental transposition flap through a Petit triangle tunnel was successfully performed. Omental transposition provides a safe option for salvage treatment of irradiated, infected lumbosacral wounds. The plastic and trophic qualities of the omentum make it an excellent choice to fill poorly vascularized wounds. In addition to its immunologic and neoangiogenic properties, the omentum has a dense lymphatic network with tremendous absorptive potential. Its biologic advantages must be weighed against the need for celiotomy and available local options according to circumstances.