Radiographic Implications of Fat Grafting to the Reconstructed Breast.

Autologous fat transfer is often used to smooth contour irregularities in the reconstructed breast. A potential concern with this technique is that it results in calcified lesions in the breast that can complicate subsequent cancer surveillance. The purpose of this review was to determine how fat grafting to the reconstructed breast impacts postoperative breast imaging. This is a matched cohort analysis of patients who underwent postmastectomy breast reconstruction with and without fat grafting as a secondary procedure. Nonfat grafted reconstructive patients were matched based on age, year of initial reconstruction, and type of reconstruction. Postoperative imaging at our institution was required for inclusion. The two groups were compared in terms of incidence and distribution of radiographic studies performed in follow-up and the need for biopsies. Fifty-one reconstructed breasts with a history of fat grafting were compared to 51 nonfat grafted, reconstructed breasts. The fat grafted group underwent a total of 204 breast imaging studies over a mean follow-up of 4.2 years, while the nonfat grafted group underwent 167 studies over 4.1 years (p = 0.21). More mammograms, ultrasounds, and magnetic resonance images were performed after fat grafting, but a significant difference was evident only for mammography (34 versus 12, p = 0.05). The incidence of breast biopsy to clarify abnormal imaging was nonsignificantly higher in the fat grafted group (17.6% versus 7.8%, p = 0.14). Fewer than 10 percent of imaging studies in the fat grafted cohort were performed to investigate a clinical or radiographic abnormality occupying the same breast quadrant as prior fat injection. Breast cancer patients treated with fat grafting required more breast imaging and biopsies than their nonfat grafted counterparts, but the areas of suspicion poorly corresponded to the site of prior fat grafting. Multimodal breast reconstruction may drive the additional diagnostic burden and not the fat grafting technique itself.

Patient-Reported Quality of Life After Breast Reconstruction: A One-Year Longitudinal Study Using the WHO-QOL Survey.

BACKGROUND: Patient-reported quality of life (QOL) is an important measure of the impact that breast reconstruction has on postmastectomy patients. This study seeks to describe psychosocial outcomes after breast reconstruction and to identify factors that influence them. METHODS: All patients who underwent immediate postmastectomy reconstruction by the senior author between 2009 and 2011 were offered participation in this study. Patients completed the World Health Organization QOL-BREF questionnaire preoperatively and 1-year postoperatively. Change scores were compared across reconstructive techniques, as well as across various demographic and clinical variables. RESULTS: One hundred twenty-nine women completed the preoperative questionnaire, and 60 patients completed the follow-up questionnaire at 1 year (response rate, 46.5%). Compared to the preoperative baseline, overall QOL was unchanged, general satisfaction with health improved significantly, and QOL in physical, psychological, social, and environmental domains decreased (P < 0.05 for all but social domains). On bivariate analysis, being in a relationship at the time of reconstruction was associated with a decline in overall QOL, as well as the quality of social relationships and environment. Educational level impacted how physical and psychological wellness evolved after surgery. Patients with a higher cancer stage reported a decrease in satisfaction with health at 1 year. Type of reconstruction, development of a complication, and need for additional surgery did not influence any of these outcomes. CONCLUSIONS: At 1-year follow-up from postmastectomy reconstruction, breast cancer survivors report a similar overall QOL, but significant decrements in physical, psychological, and environmental QOL. Satisfaction with health improved. The type of breast reconstruction did not influence any of these outcomes.

Ventral hernia repair after bowel surgery: does gastrointestinal contamination matter in the era of biologic mesh?

BACKGROUND: Ventral hernias are often repaired after planned or unplanned bowel procedures. Biologic materials are thought to better tolerate gastrointestinal contamination than synthetic alternatives. The purpose of this review was to evaluate the impact of intestinal contamination on ventral hernia repair with biologic material. METHODS: This is a retrospective review of all patients who underwent ventral hernia repair with biologic material between 2003 and 2012. Groups were defined based on performance of concomitant bowel surgery. Data were collected on patient demographics, risk factors, concomitant procedures, mesh type, and outcomes. RESULTS: Of 82 patients included in this series, 32 (39%) had concomitant bowel surgery. Ventral hernia repair was performed predominantly with Alloderm and Strattice. There was no difference in hernia recurrence (contaminated group-28% vs. non-contaminated group-34%, P = 0.58), surgical site infections (contaminated-28% vs. non-contaminated-20%, P = 0.40), or other complications when patients with and without concomitant bowel surgery were compared. CONCLUSIONS: Biologic materials have made it such that ventral hernias can be safely repaired after bowel surgery without increased risk of complications.

Predictors of contralateral prophylactic mastectomy and the impact on breast reconstruction.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is being performed with increased frequency. Predictors of CPM and their impact on breast reconstruction are examined. METHODS: A retrospective review of a dually trained oncologic and plastic surgeon's experience with patients undergoing total mastectomy from 2002 to 2012 was performed. Patients who underwent bilateral therapeutic mastectomies or who had previous contralateral mastectomy were excluded from this series. RESULTS: Four hundred forty-six patients were treated with total mastectomy and 174 (39%) underwent CPM. The incidence of CPM nearly tripled over the period studied. Compared to women treated with unilateral mastectomy, women who elected for CPM were younger (mean age, 50.4 vs 56.8 years, P < 0.001), leaner (mean body mass index, 26.1 vs 27.4 kg/m2, P = 0.036), more often white (86.8% vs 73.8%, P = 0.004), and more often had a family history of breast cancer (52% vs 33.3%, P < 0.001). The CPM group was also more likely to have undergone a preoperative magnetic resonance imaging (56.3% vs 39%, P < 0.001) and to have stage I disease (31% vs 22.8%, P = 0.053). They were less likely to have undergone prior attempts at breast conservation (6.9% vs 15.8%, P = 0.004) and considerably more likely to pursue breast reconstruction (83.9% vs 63.6%, P < 0.001). Multivariate analysis confirmed age, white race, family history, prior attempt at breast conservation, and receipt of breast reconstruction to be independently associated with prophylactic mastectomy. Incidental contralateral cancers were discovered in 4% of women who underwent CPM (n = 7), lobular carcinoma in situ in 2.3% (n = 4), and atypical lesions in an additional 11.6% (n = 20). Women who underwent CPM favored reconstruction with breast implants (60.9% vs 17.3%), whereas the transverse rectus abdominis musculocutaneous flap predominated among their unilateral counterparts (38.6% vs 15.5%). Among women who underwent immediate breast reconstruction, the addition of a contralateral procedure expectedly increased breast complication rates (50.3% vs 35.0%, P = 0.007), especially the more severe complications that required hospitalization or reoperation (18.6% vs 5.0%, P < 0.001). CONCLUSIONS: The incidence of CPM is increasing and is associated with younger age, white race, family history, and the use of breast reconstruction. Implant-based reconstructions predominate in this cohort. The added morbidity of a contralateral procedure is significant.

The management of abdominal contour defects following TRAM flap breast reconstruction.

BACKGROUND: Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging. OBJECTIVES: The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair. METHODS: All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified. RESULTS: Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement. CONCLUSIONS: Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.