A Prospective Randomized Trial of the Efficacy of Fibrin Glue, Triamcinolone Acetonide, and Quilting Sutures in Seroma Prevention after Latissimus Dorsi Breast Reconstruction.

BACKGROUND: Donor-site seroma is the most common complication following latissimus dorsi flap breast reconstruction. Various agents and techniques have attempted to minimize seroma formation. The purpose of this study was to compare the efficacy of different products and quilting sutures at seroma prevention. METHODS: This is a single-center, double-blinded, randomized, controlled trial of a consecutive series of breast cancer patients (n = 96) undergoing latissimus dorsi flap reconstruction performed by a single surgeon. Patients were randomized to receive (1) fibrin glue (Tisseel) (n = 23), (2) triamcinolone acetonide (n = 26), or (3) normal saline (control) (n = 27) sprayed into the donor site. The fourth arm included donor-site quilting sutures (n = 20). Outcomes included seroma, drain output, and days to last drain removal. Drain removal was standardized at less than 30 cc/day. RESULTS: All groups were matched evenly without differences in risk, procedures, or complications. The overall seroma rate was 31.3 percent (n = 30). The quilting group had significantly less drainage for weeks 1 (p = 0.006) and 2 (p = 0.050) postoperatively. Quilting statistically reduced the incidence of seromas to 5.0 percent (n = 1; p = 0.038) compared with other groups (control, 34.5 percent; fibrin, 27.6 percent; and triamcinolone, 37.6 percent). Drains were removed 10 days earlier with quilting (control, 35.5 days; fibrin, 39.5 days; triamcinolone, 37.4 days; and quilting, 25.8 days; p = 0.001). The incidence of all other complications was similar between groups. CONCLUSION: The use of quilting donor sites significantly decreases the incidence of donor-site seromas and leads to earlier drain removal following latissimus dorsi flap reconstruction and maintains a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Impact of Diabetes Mellitus on Wound Healing in Breast Reconstruction.

BACKGROUND: Although diabetes mellitus (DM) is a known risk factor for surgical complications in general, there is little published evidence to establish such an effect among patients undergoing breast reconstruction (BR). The purpose of this study was to assess the impact of DM on complications in patients undergoing postmastectomy BR. METHODS: Patients who underwent BR at our institution from November 2002 to November 2012 were identified. Clinical and demographic data of patients with type 1 or type 2 DM were reviewed. Complications occurring within 60 days of surgery were compared between diabetic and nondiabetic patients for both autologous and nonautologous reconstruction types. RESULTS: A total of 1371 BR were performed in 1035 patients. There were 877 (64.0%) autologous reconstructions and 494 (36.0%) implant-based reconstructions. Patients with DM (n = 64) had significantly higher preoperative blood glucose levels (137.5 vs 100.1, P < 0.05). Postoperatively, DM patients reconstructed with implants had a significantly higher incidence of delayed wound healing (22.2% vs 9.7%; P = 0.04). This was not observed in patients with DM reconstructed with autologous tissue (7.4% vs 6.6%; P = 0.70). Diabetic patients had a significantly higher incidence of hypertension and were older than nondiabetic patients. To control for these variables and other potential confounders, multiple logistic regression analysis was performed. Again, diabetic patients had a significantly higher incidence of delayed wound healing following implant-based reconstruction (odds ratio, 2.52, 95% confidence interval = 1.2-6.2) but not autologous reconstruction (odds ratio, 0.97; 95% confidence interval = 0.2-4.6). CONCLUSIONS: Diabetes heightens the risk of wound healing complications among patients undergoing implant-based reconstruction.

The Psychosexual Impact of Postmastectomy Breast Reconstruction.

BACKGROUND: The surgical management of breast cancer with mastectomy and breast reconstruction (BR) has been shown to increase the quality of life of cancer survivors. Yet the impact of surgery on sexuality, femininity, and condition of intimate relationships as a measure for sexual health has not been fully evaluated. METHODS: Ninety-six women who underwent mastectomy and immediate BR participated in the series. Surveys assessed patients' level of sexual health in the areas of femininity, sexual confidence during intimate relationships, and the role of breast sensibility in sexual satisfaction as compared with how they felt preoperatively. Surveys were scored on a 5-point Likert scale (5 = strongly agree). Inclusion criteria included longer than 1 year follow-up. RESULTS: After BR, the majority felt that their breasts were as important to self-confidence (86.3%), femininity (84.0%), and sexuality (61.5%) as they were preoperatively. Women older than 50 years were more likely to feel that their breasts were not a significant part of their femininity (26.7% vs 11.8%, P = 0.05). Women with a BMI greater than 30 were more likely to feel that their partner's view of their breasts did not affect their self-confidence (46.2% vs. 20.7%P = 0.027). Women with a BMI less than 30 (23.2% vs 4.0%, P = 0.05), and those who had a major complication (22.2% vs 0.00%, P = 0.08) were more likely to disagree that nipple aerolar complex reconstruction improved their sexual confidence. CONCLUSIONS: Most women agree that their sexuality, femininity, and intimate relationships are maintained after BR. Increasing age and BMI may lead to changes in sexual health postoperatively.

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.

The use of reduction mammaplasty with breast conservation therapy: an analysis of timing and outcomes.

BACKGROUND: Oncoplastic reduction mammaplasty is often used to prevent or correct breast conservation therapy deformities. The purpose of this review was to evaluate surgical outcomes, patient satisfaction, and aesthetic outcomes of this procedure when performed before or after radiation therapy. METHODS: Breast cancer patients treated with breast conservation therapy and reduction mammaplasty between 2005 and 2012 were divided into immediate reconstruction, delayed immediate reconstruction, and delayed reconstruction. Greater than 6-month follow-up was required for inclusion. Patient demographics and clinical outcomes, including complications, patient satisfaction, and aesthetic result, were queried. Patient satisfaction was determined using the BREAST-Q survey. Postoperative photographs were used to rate aesthetic outcomes blinded to the timing of the procedure. RESULTS: Patients in the immediate reconstruction group had fewer complications (immediate reconstruction, 20.5 percent; delayed immediate reconstruction, 33.3 percent; delayed reconstruction, 60.0 percent; p < 0.001) and asymmetry (immediate reconstruction, 8.5 percent; delayed immediate reconstruction, 44.4 percent; delayed reconstruction, 24.0 percent; p < 0.001), and required fewer procedures to complete the reconstruction (immediate reconstruction, 1.2; delayed immediate reconstruction, 2.4; delayed reconstruction, 2.2; p < 0.001). Delayed reconstruction resulted in higher complication and fat necrosis rates (immediate reconstruction, 0.9 percent; delayed immediate reconstruction, 0.0 percent; delayed reconstruction, 8.0 percent; p = 0.047). Although patient satisfaction and aesthetic outcomes were better in the immediate reconstruction group, this difference was not statistically significant. CONCLUSIONS: Oncoplastic reduction techniques performed before radiation therapy result in fewer complications. Good patient satisfaction and aesthetic outcomes can be achieved when reduction is performed before or after radiation therapy, but patient selection and education are important. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evaluating outcomes after correction of the breast conservation therapy deformity.

BACKGROUND: In an effort to preserve the native breast shape, most women with breast cancer are treated with breast conservation therapy (BCT). However, a breast deformity can develop after BCT and can be challenging to repair. The goal of this review was to evaluate outcomes based on the extent of the deformity and reconstructive technique. METHODS: Sixty-three patients treated for a BCT deformity between 2003 and 2012 were included. Data queried included demographics, extent of the deformity, type of reconstruction, and outcomes. A panel judged aesthetic outcomes, and patient satisfaction was determined using the validated Breast Q reconstruction questionnaire. Comparisons were made across reconstructive techniques. RESULTS: There were 22 grade I/II deformities, and 29 grade III/IV deformities. Local scar revision procedures and fat grafting were more common for grade I, and myocutaneous flaps were more common for grade IV. Bilateral reduction techniques (n = 20) and contralateral reduction only (n = 6) were most common for grade II/III defects. Augmentation was used in 9 grade III patients. Combined reconstructive techniques were required in 23% of the patients. Eighty-nine percent had a contralateral symmetry procedure. Complications occurred in 34.9%, with no significant variation across the different modes of reconstruction. There was a trend toward higher complication rates with increasing defect severity (0% for grade 1, 32% for grade 2, 39% for grade 3, and 50% for grade 4). Patients required an average of 1.3 procedures (range, 1-3), at an average follow-up of 2.5 years. Eighty percent of patients had only 1 reconstructive operation, 14% required a second operation, and 6% a third. Patient satisfaction was generally high and the mean aesthetic rating was 5 out of 7, and trended down with the extent of the deformity. Patients who underwent contralateral reduction only had the highest aesthetic scores (5.8/7). CONCLUSIONS: Reconstructive options for the correction of BCT deformities are numerous and need to be appropriately tailored for each patient in part based on the extent of the deformity. Although revisions are not uncommon, good patient satisfaction and esthetic outcomes can be achieved.

The Psychosexual Impact of Partial and Total Breast Reconstruction: A Prospective One-Year Longitudinal Study.

BACKGROUND: This prospective trial sought to explore patients' satisfaction and expectations for surgery in the areas of sexuality and body image and to evaluate outcomes pertaining to sexual well-being after total and partial breast reconstruction (BR). METHODS: Patients who underwent mastectomy and immediate total BR (group 1; n = 60) or lumpectomy and reduction mammoplasty (group 2; n = 10) completed a questionnaire preoperatively and 1 year postoperatively to assess their satisfaction with their sex life and body image, perceptions of breasts as a source of sexuality, and expectations of surgery in these areas. Surveys were scored on a 5-point Likert scale, with 5 indicating strongly agree. Change scores were evaluated in the 2 groups (P = 0.05). RESULTS: In group 1, satisfaction with sex life and body image was unchanged. Pursuit of sexual attractiveness (from 3.78 to 3.31, P = 0.02) and an improved body image (from 3.89 to 3.33, P < 0.01) were cited as expectations for surgery but were achieved less often. When stratified by different types of reconstruction, there were no discernible differences in responses. In group 2, the patients reported an unexpected increase in their partner's perception of them as womanly (from 1.33 to 2.50, P = 0.01) and greater gains in the ability to wear sexually provocative clothing (from 1.78 to 3.11, P < 0.01).Preoperative expectations for improved body image were more often met in group 2 than group 1 (from 3.60 to 4.00 vs from 3.89 to 3.33, P = 0.02). Group 2 experienced greater improvement in body image satisfaction (from 2.80 to 3.80 vs from 3.37 to 3.44, P = 0.03). CONCLUSIONS: Overall satisfaction with sex life and body image was preserved for both groups; however, the oncoplastic approach achieved significantly larger gains in body image perception.

The oncoplastic reduction approach to breast conservation therapy: benefits for margin control.

BACKGROUND: Reduction mammaplasty during lumpectomy allows more generous resection and minimizes potential for poor cosmesis as compared with breast conservation therapy alone. OBJECTIVES: The authors assessed the benefits of oncoplastic reduction for margin status in patients with breast cancer by conducting a retrospective review of cases of tumor resection alone vs tumor resection with oncoplastic reduction. METHODS: Patients with breast cancer who underwent lumpectomy performed by a single oncologic surgeon between 2009 and 2013 were included. Patients were stratified into 2 groups based on surgical procedure: tumor resection with oncoplastic reduction (group 1) vs tumor resection alone (group 2). Patient demographics including risk factors, diagnosis, cancer stage, and procedure type were recorded. Tumor size, specimen weight, width of narrowest margin, and receptor status were determined. Outcome variables included margin positivity (≤1 mm), need for re-excision, and conversion to completion mastectomy. RESULTS: A total of 222 breasts from 207 patients were included in the study: 83 in group 1 and 139 in group 2. The patients in group 1 had a lower incidence of positive margins and wider free surgical margins, required re-excision less often, and went on to completion mastectomy less often. Patients in group 1 were younger and had cancer that was more advanced. When controlling for these variables on multivariate regression analysis, the oncoplastic technique was independently associated with fewer positive margins and fewer instances of re-excision. CONCLUSIONS: The oncoplastic reduction technique achieves wider free margins and less often necessitates re-excision or subsequent mastectomy. The long-term oncologic effect of this approach deserves further study. LEVEL OF EVIDENCE: 4.

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 effect of radiation on acellular dermal matrix and capsule formation in breast reconstruction: clinical outcomes and histologic analysis.

BACKGROUND: The authors compared clinical outcomes to determine whether acellular dermal matrix altered the capsular tissue architecture in irradiated and nonirradiated breasts following matrix-assisted expander reconstruction. METHODS: Part I included all 27 patients who underwent bilateral tissue expander reconstruction with acellular dermal matrix between 2007 and 2012 and subsequent unilateral radiation therapy. Part II included a subset of patients with capsular biopsy specimens taken at the time of implant exchange for histologic analysis. Specimens included irradiated and nonirradiated acellular dermal matrix and irradiated and nonirradiated native capsule. Clinical outcomes were analyzed in relation to capsule architecture and acellular dermal matrix performance. RESULTS: In part I, mean follow-up was 28 months. Grade III/IV contractures were identified in nine patients (all on the irradiated side), and 12 developed noncontracture complications (75 percent on the irradiated side). Nine patients were unable to continue with implant reconstruction and required salvage with autologous tissue. In part II, postirradiation biopsy specimens were taken of the peri-implant capsule in six patients at the time of secondary surgery. Elastin content and the total cellular infiltrate were significantly greater in the irradiated versus nonirradiated native capsules (p = 0.0015). Conversely, the irradiated matrix capsule was composed of similar amounts of cellular infiltrate and collagen as the nonirradiated matrix capsules and nonirradiated native capsules. Irradiated acellular dermal matrix showed the least amount of alpha-smooth actin staining but a similar number of blood vessels. CONCLUSION: Acellular dermal matrix appears to limit the elastosis and chronic inflammation seen in irradiated implant reconstructions and is potentially beneficial in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.