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Implant-based reconstructions are increasingly utilized following mastectomy in the prevention and treatment of breast cancer. However, these implants are associated with a high rate of infection, which is a major complication that can lead to implant removal, delay in adjuvant radiation and chemotherapy, and increase in health care costs. Early clinical signs and symptoms of infection, such as erythema, warmth, and tenderness, are challenging to discern from expected postsurgical responses. Furthermore, when atypical features are present or the patient's condition does not improve on adequate antimicrobials, the clinician should be prompted to consider an alternative noninfectious etiology. Herein we highlight the key elements of the preventive, diagnostic, and multidisciplinary therapeutic approach to salvaging the infected breast implant; review several infectious disease mimickers; and provide many pearls of wisdom that the practicing clinician must be familiar with and be able to manage in an effective and successful manner.
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Implantes de Mama , Infecciones Relacionadas con Prótesis , Humanos , Implantes de Mama/efectos adversos , Femenino , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/prevención & control , Infecciones Relacionadas con Prótesis/terapia , Neoplasias de la Mama/cirugía , Mamoplastia/efectos adversos , Implantación de Mama/efectos adversos , Antibacterianos/uso terapéutico , MastectomíaRESUMEN
BACKGROUND: It is not clear whether mesh-reinforced anterior component separation (CS) for abdominal wall reconstruction (AWR) results in better outcomes than mesh-reinforced primary fascial closure (PFC) without CS, particularly when acellular dermal matrix is used. The authors compared outcomes of CS versus PFC repair in AWR procedures aiming to determine whether CS results in better outcomes. METHODS: This retrospective study of prospectively collected data included 461 patients who underwent AWR with acellular dermal matrix during a 10-year period at an academic cancer center. The primary endpoint was hernia recurrence; the secondary outcome was surgical-site occurrence (SSO). RESULTS: A total of 322 patients (69.9%) who underwent mesh-reinforced AWR with CS (AWR-CS) and 139 (30.1%) who underwent AWR with PFC (AWR-PFC) without CS were compared. AWR-PFC repairs had a higher hernia recurrence rate than AWR-CS repairs (10.8% versus 5.3%; P = 0.002) but similar overall complication (28.8% versus 31.4%; P = 0.580) and SSO (18.7% versus 25.2%; P = 0.132) rates. CS repairs experienced significantly higher wound separation (17.7% versus 7.9%; P = 0.007), fat necrosis (8.7% versus 2.9%; P = 0.027), and seroma (5.6% versus 1.4%; P = 0.047) rates than PFC repairs. The best cutoff with respect to hernia recurrence was 7.1 cm of abdominal defect width. CONCLUSION: AWR-CS repair resulted in a lower hernia recurrence rate than AWR-PFC but, despite the additional surgery, had similar SSO rates on long-term follow-up. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Pared Abdominal , Productos Biológicos , Hernia Ventral , Humanos , Pared Abdominal/cirugía , Hernia Ventral/cirugía , Estudios Retrospectivos , Músculos Abdominales/cirugía , Mallas Quirúrgicas , Herniorrafia/efectos adversos , Herniorrafia/métodos , Resultado del Tratamiento , Recurrencia Local de Neoplasia/cirugía , RecurrenciaRESUMEN
BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. We aimed to evaluate outcomes of VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction. METHODS: We conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January 2001 and March 2021. Our primary outcome measure included recipient and donor surgical site occurrences (SSOs). RESULTS: We identified a total of 546 patients (55% females) with a mean age was 58 years and mean BMI was 27 kg/m 2. Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient-site SSOs occurred in 38% of patients while donor-site SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients while bulge developed in 6.4% of patients. Cox proportional hazards regression model for hernia occurrence identified age, BMI, tobacco use (HR 2.03, 95% CI [1.02 - 4.04]) and use as an extended VRAM (HR 2.13, 95% CI [1.04 - 4.36]). The use of mesh or component separation were not independent protective factors for hernia occurrence. CONCLUSION: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor site hernia occurrence.
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BACKGROUND: Incisional hernia (IH) is common after major abdominal surgery; however, the incidence after hepatectomy for cancer has not been described. We analyzed incidence of and risk factors for IH after hepatectomy for colorectal liver metastases (CLM). METHODS: Patients who underwent open hepatectomy with midline or reverse-L incision for CLM at a single institution between 2010 and 2018 were retrospectively analyzed. Postoperative CT scans were reviewed to identify IH and the time from hepatectomy to hernia. Cumulative IH incidence was calculated using competing risk analysis. Risk factors were assessed using Cox proportional hazards model analysis. The relationship between IH incidence and preoperative body mass index (BMI) was estimated using a generalized additive model. RESULTS: Among 470 patients (median follow-up: 16.9 months), IH rates at 12, 24, and 60 months were 41.5%, 51.0%, and 59.2%, respectively. Factors independently associated with IH were surgical site infection (HR: 1.54, 95% CI 1.16-2.06, P = 0.003) and BMI > 25 kg/m2 (HR: 1.94, 95% CI 1.45-2.61, P < 0.001). IH incidence was similar in patients undergoing midline and reverse-L incisions and patients who received and did not receive a bevacizumab-containing regimen. The 1-year IH rate increased with increasing number of risk factors (zero: 22.2%; one: 46.8%; two: 60.3%; P < 0.001). Estimated IH incidence was 10% for BMI of 15 kg/m2 and 80% for BMI of 40 kg/m2. CONCLUSION: IH is common after open hepatectomy for CLM, particularly in obese patients and patients with surgical site infection. Surgeons should consider risk-mitigation strategies, including alternative fascial closure techniques.
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Neoplasias Colorrectales , Hernia Incisional , Neoplasias Hepáticas , Humanos , Hernia Incisional/epidemiología , Hernia Incisional/etiología , Hernia Incisional/cirugía , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Hepatectomía/efectos adversos , Estudios Retrospectivos , Incidencia , Factores de Riesgo , Neoplasias Hepáticas/complicaciones , Neoplasias Colorrectales/cirugía , Neoplasias Colorrectales/patologíaRESUMEN
BACKGROUND: Autologous fat grafting is a useful tool in breast reconstruction. The authors have previously demonstrated a difference in the rate of processing adipose grafts in a randomized time and motion clinical trial. The purpose of this study was to compare clinical outcomes in commonly used grafting systems. METHODS: Three methods to prepare adipose grafts were compared: a passive washing filtration system (Puregraft system), an active washing filtration system (Revolve system), and centrifugation (Coleman technique). Postoperative complications, rates of fat necrosis, revision procedures, and additional imaging were recorded. RESULTS: Forty-six patients were included in the prospective, randomized study (15 active filtration, 15 passive filtration, and 16 centrifugation). Their mean age was 54 years and mean body mass index was 28.6 kg/m 2 . The mean length of follow-up was 16.9 ± 4 months. The overall complication rate was 12.1 percent. The probability of fat necrosis was no different between the groups (active filtration, 15 percent versus passive filtration, 14.3 percent] versus centrifugation, 8 percent; p = 0.72). Fat necrosis was highest in patients with breast conservation before grafting (60 percent; p = 0.011). There was no significant difference in contour irregularity (active filtration, 40 percent versus passive filtration, 38 percent versus centrifugation, 36 percent; p = 0.96) or additional grafting (active filtration, 40 percent versus passive filtration, 24 percent versus centrifugation, 32 percent; p = 0.34). CONCLUSIONS: This is the first prospective, randomized study to compare clinical outcomes of adipose graft preparation. There was no significant difference in early complications, fat necrosis, or rates of additional grafting among the study groups. There was significantly higher risk of fat necrosis in patients with previous breast conservation treatment regardless of processing technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
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Necrosis Grasa , Mamoplastia , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Necrosis Grasa/etiología , Trasplante Autólogo , Mamoplastia/efectos adversos , Mamoplastia/métodos , Tejido Adiposo/trasplante , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Ventral hernia repair (VHR) is one of the most commonly performed procedures in the United States, but studies assessing the long-term outcomes of VHR using biologic mesh are scarce. OBJECTIVE: We sought to determine the rates of hernia recurrence (HR) and surgical site occurrences (SSOs) in a large cohort of patients who underwent AWR with biologic mesh. METHODS: We conducted a retrospective cohort study of patients who underwent AWR using either porcine ADM (PADM) or bovine ADM (BADM) from 2005 to 2019. We analyzed the full cohort and a subset of our population with minimum long-term follow-up (LTF) of 5 years. The primary outcome measure was HR. Secondary outcomes were SSOs. RESULTS: We identified a total of 725 AWRs (49.5% PADM, 50.5% BADM). Mean age was 69 ± 11.5 years and mean body mass index was 31 ± 7 kg/m 2 . Forty-two percent of the defects were clean at the time of AWR, 44% were clean-contaminated, and 14% were contaminated/infected. Mean defect size was 180 ± 174 cm 2 , mean mesh size was 414 ± 203 cm 2 . Hernia recurred in 93 patients (13%), with cumulative HR rates of 4.9%, 13.5%, 17.3%, and 18.8% at 1, 3, 5, and 7 years, respectively. There were no differences in HR ( P = 0.83) and SSO ( P = 0.87) between the 2 mesh types. SSOs were identified in 27% of patients. In our LTF group (n = 162), the HR rate was 16%. Obesity, bridged repair, and concurrent stoma presence/creation were independent predictors of HR; component separation was protective against HR. CONCLUSIONS: Despite its use in complex AWR, ADM provides durable long-term outcomes with relatively low recurrence rates.
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Pared Abdominal , Dermis Acelular , Productos Biológicos , Hernia Ventral , Pared Abdominal/cirugía , Animales , Bovinos , Estudios de Seguimiento , Hernia Ventral/cirugía , Herniorrafia/métodos , Recurrencia Local de Neoplasia/cirugía , Recurrencia , Estudios Retrospectivos , Mallas Quirúrgicas , Porcinos , Resultado del TratamientoRESUMEN
"Time burden" (time required during treatment) is relevant when choosing a local therapy option for early-stage breast cancer but has not been rigorously studied. We compared the time burden for three common local therapies for breast cancer: (1) lumpectomy plus whole-breast irradiation (Lump+WBI), (2) mastectomy without radiation or reconstruction (Mast alone), and (3) mastectomy without radiation but with reconstruction (Mast+Recon). METHODS: Using the MarketScan database, we identified 35,406 breast cancer patients treated from 2000 to 2011 with these local therapies. We quantified the total time burden as the sum of inpatient days (inpatient-days), outpatient days excluding radiation fractions (outpatient-days), and radiation fractions (radiation-days) in the first two years postdiagnosis. Multivariable regression evaluated the effect of local therapy on inpatient-days and outpatient-days adjusted for patient and treatment covariates. RESULTS: Adjusted mean number of inpatient-days was 1.0 for Lump+WBI, 2.0 for Mast alone, and 3.1 for Mast+Recon (P < 0.001). Adjusted mean number of outpatient-days was 42.9 for Lump+WBI, 42.2 for Mast alone, and 45.8 for Mast+Recon (P < 0.001). The mean number of radiation-days for Lump+WBI was 32.4. Compared with Mast+Recon (48.9 days), total adjusted time burden was 4.7 days shorter for Mast alone (44.2 days) and 27.4 days longer for Lump+WBI (76.3 days). However, use of a 15 fraction WBI regimen would reduce the time burden differential between Lump+WBI and Mast+Recon to just 10.0 days. CONCLUSIONS: Although Mast+Recon confers the highest inpatient and outpatient time burden, Lump+WBI carries the highest total time burden. Increased use of hypofractionation will reduce the total time burden for Lump+WBI.
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BACKGROUND: Time and motion studies provide a reliable methodology to quantify efficiency and establish recommendations for best practices in autologous fat grafting. The purpose of this study was to compare the rate of graft processing of three frequently used systems for graft preparation. METHODS: The authors conducted a prospective randomized comparison of three methods to prepare adipose tissue for autologous fat grafting: an active filtration system (Revolve; LifeCell Corporation, Branchburg, N.J.), a passive filtration system (PureGraft 250; Cytori Therapeutics, San Diego, Calif.), and centrifugation. An independent observer collected data according to the study's behavioral checklist. The primary outcome measure was rate of adipose tissue processed. RESULTS: Forty-six patients (mean age, 54 years; mean body mass index, 28.6 kg/m2) were included in the study (15 per arm; one patient was included with intention to treat after a failed screening). The rate of adipose tissue preparation was greater for the active filtration system compared with the others (active filtration: 9.98 ml/min versus passive filtration: 5.66 ml/min versus centrifugation: 2.47 ml/min). Similarly, there was a significant difference in total grafting time (active: 82.7 ± 8.51 minutes versus passive: 152 ± 13.1 minutes, p = 0.0005; versus centrifugation: 209.9 ± 28.5 minutes, p = 0.0005); however, there was no difference in total operative time (p = 0.82, 0.60). CONCLUSIONS: As the number of fat grafting procedures increases, there is interest in developing techniques to harvest, process, and inject fat to improve clinical outcomes and operative efficiency. The results of this study indicate that an active fat processing system is more time efficient at graft preparation than a passive system or centrifugation.
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Tejido Adiposo/trasplante , Recolección de Tejidos y Órganos/métodos , Trasplante Autólogo/métodos , Adulto , Anciano , Centrifugación , Femenino , Filtración , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios de Tiempo y MovimientoRESUMEN
BACKGROUND: With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs. OBJECTIVES: The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction. METHODS: A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed. RESULTS: From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14). CONCLUSIONS: Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction.
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Dermis Acelular , Implantación de Mama , Implantes de Mama , Neoplasias de la Mama , Mamoplastia , Aloinjertos , Animales , Implantación de Mama/efectos adversos , Implantes de Mama/efectos adversos , Neoplasias de la Mama/cirugía , Bovinos , Femenino , Xenoinjertos , Humanos , Mamoplastia/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Mallas Quirúrgicas/efectos adversos , Dispositivos de Expansión Tisular/efectos adversosRESUMEN
BACKGROUND: The relationship between treatment-related, cost-associated distress "financial toxicity" (FT) and quality-of life (QOL) in breast cancer patients remains poorly characterized. This study leverages validated patient-reported outcomes measures (PROMs) to analyze the association between FT and QOL and satisfaction among women undergoing ablative breast cancer surgery. STUDY DESIGN: This is a single-institution cross-sectional survey of all female breast cancer patients (>18 years old) who underwent lumpectomy or mastectomy between January 2018 and June 2019. FT was measured via the 11-item COmprehensive Score for financial Toxicity (COST) instrument. The BREAST-Q and SF-12 were used to asses condition-specific and global QOL, respectively. Responses were linked with demographic and clinical data. Pearson correlation coefficient and multivariable regression were used to examine associations. RESULTS: Our analytical sample consisted of 532 patients; mean age 58, mostly white (76.7%), employed (63.7%), married/committed (73.7%), with 64.3% undergoing reconstruction. Median household income was $80,000 to $120,000/year, and mean COST score was 28.0. After multivariable adjustment, a positive relationship for all outcomes was noted; lower COST (greater cost-associated distress) was associated with lower BREAST-Q and SF-12 scores. This relationship was strongest for BREAST-Q psychosocial well-being, for which we observed a 0.89 (95% CI 0.76-1.03) change per unit change in COST score. CONCLUSIONS: Financial toxicity captured in this study correlates with statistically significant and clinically important differences in BREAST-Q psychosocial well-being, patient satisfaction with reconstructed breasts, and SF-12 global mental and physical quality of life. Treatment costs should be included in the shared decision-making for breast cancer surgery. Future prospective outcomes research should integrate COST.
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Neoplasias de la Mama/cirugía , Carcinoma/cirugía , Costos de la Atención en Salud , Mastectomía/economía , Satisfacción del Paciente/economía , Calidad de Vida/psicología , Adulto , Anciano , Neoplasias de la Mama/economía , Neoplasias de la Mama/psicología , Carcinoma/economía , Carcinoma/psicología , Estudios Transversales , Femenino , Estudios de Seguimiento , Encuestas de Atención de la Salud , Humanos , Modelos Lineales , Mastectomía/psicología , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Satisfacción del Paciente/estadística & datos numéricos , Estudios Retrospectivos , TexasRESUMEN
The requirement for postmastectomy radiation therapy (PMRT) at the time of mastectomy is often unknown. Autologous reconstruction is preferred in the setting of radiotherapy by providing healthy vascularized tissue to the chest. To maximize mastectomy skin preservation, tissue expander (TE) placement maintains the breast pocket until definitive reconstruction. This study aims to compare outcomes of skin-preserving delayed versus standard delayed autologous breast reconstruction in the setting of PMRT. METHODS: A retrospective review of a prospective database was performed of two patient cohorts at a single center between 2006 and 2016. Inclusion criteria were locally advanced breast cancer patients who completed PMRT and free autologous reconstruction. Primary outcomes were major intraoperative and postoperative TE and flap complications. RESULTS: Over 10 years, 241 patients underwent mastectomy and PMRT. Standard delayed autologous breast reconstruction was performed in 131 breasts (non-TE group). Skin-preserving delayed autologous reconstruction was performed in 113 breasts (TE group). The TE group was associated with a higher incidence of intraoperative complications during flap reconstruction (P = 0.002) and had a higher venous thrombosis incidence than the non-TE cohort (P = 0.007). Other major postoperative complications were not significantly different between the two groups. TE patients had 7.5 times higher risk of intraoperative complications and an 18.6% TE loss rate. CONCLUSIONS: We identified higher intraoperative flap complications and a high rate of TE loss in patients who underwent skin-preserving delayed autologous breast reconstruction. The benefit of mastectomy skin preservation needs to be weighed against the increased risk of TE loss and higher rates of flap thrombosis.
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BACKGROUND: There is ongoing debate regarding the optimal timing of contralateral prophylactic mastectomy fueled by concern that performing it at the time of the mastectomy for the index breast cancer may delay adjuvant therapy. The study objective was to examine the effect of simultaneous contralateral prophylactic mastectomy with immediate breast reconstruction on the complication rate and adjuvant therapy timing. METHODS: A retrospective study was conducted of consecutive patients who underwent contralateral prophylactic mastectomy with immediate breast reconstruction and received adjuvant therapy over a 6-year period. Demographic, treatment, and outcomes data were collected, and relationships between multiple variables and outcomes were evaluated. RESULTS: Of 241 patients (482 breasts) included, 186 (372 breasts) underwent simultaneous index breast mastectomy and contralateral prophylactic mastectomy with immediate breast reconstruction followed by adjuvant therapy (immediate group), and 55 (110 breasts) underwent index mastectomy, then adjuvant therapy, followed by delayed contralateral prophylactic mastectomy with immediate breast reconstruction (delayed group). Demographics were similar, although breast cancer stage (p < 0.001), tumor category (p = 0.0072), and nodal category (p < 0.001) were significantly higher in the delayed group. In the immediate group, complications before adjuvant therapy occurred in 31 patients (16.7 percent), and in six patients (3.2 percent) complications occurred only in the contralateral prophylactic mastectomy breast; delay to adjuvant therapy occurred in 11 patients (5.9 percent), in four (2.2 percent) of whom the contralateral prophylactic mastectomy breast was responsible for the delay. CONCLUSIONS: Contralateral prophylactic mastectomy with immediate breast reconstruction can be performed safely at the time of the index mastectomy in carefully selected patients. These findings will engage patients seeking contralateral prophylactic mastectomy in shared decision-making regarding optimal timing with respect to the risks and benefits. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Neoplasias de la Mama/cirugía , Quimioterapia Adyuvante , Mamoplastia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Mastectomía Profiláctica/efectos adversos , Radioterapia Adyuvante , Tiempo de Tratamiento , Adulto , Femenino , Humanos , Mastectomía/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Factores de TiempoRESUMEN
PURPOSE: The identification of patient-specific risk factors, which predict morbidity following abdominally based microvascular breast reconstruction is difficult. Sarcopenia is a proxy for patient frailty and is an independent predictor of complications in a myriad of surgical disciplines. We predict that sarcopenic patients will be at higher risk for surgical complications following abdominally based microvascular breast reconstruction. METHODS: A retrospective study of all patients who underwent delayed abdominally based autologous breast reconstruction following postmastectomy radiation therapy from 2007 to 2013 at a single institution was conducted. Univariate and multiple logistic regression models were used to assess the effect of sarcopenia on postoperative outcomes. RESULTS: Two hundred and eight patients met the inclusion criteria, of which 30 met criteria for sarcopenia (14.1%). There were no significant differences in demographics between groups. There were no significant differences in minor (36.7% vs 44.4%; P = .43) or major (16.7% vs 25.3%; P = .36) complications between groups as well as hospital length of stay. Multivariable logistic regression demonstrated that a staged reconstruction with the use of a tissue expander was the only consistent variable, which predicted major complications (OR, 2.24; 95% CI, 1.18-4.64; P = .015). CONCLUSIONS: Sarcopenia does not predispose to minor or major surgical complications in patients who undergo abdominally based microsurgical breast reconstruction.
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Abdomen/cirugía , Neoplasias de la Mama/cirugía , Colgajos Tisulares Libres/efectos adversos , Mamoplastia/efectos adversos , Mastectomía/efectos adversos , Complicaciones Posoperatorias/diagnóstico , Sarcopenia/fisiopatología , Neoplasias de la Mama/patología , Femenino , Estudios de Seguimiento , Colgajos Tisulares Libres/trasplante , Humanos , Persona de Mediana Edad , Atención Perioperativa , Complicaciones Posoperatorias/etiología , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Trasplante AutólogoRESUMEN
Lymphedema is a debilitating clinical condition predominantly affecting survivors of cancer. It adversely affects patients' quality of life and results in substantial cost burdens to both patients and the healthcare system. Specialist lymphedema care is optimally provided within integrated clinical programs that align the necessary specialties to provide patient-focused, multidisciplinary, structured, and coordinated care. This article examines our experience building a specialist lymphedema academic program. METHODS: We describe the critical components necessary for constructing a multidisciplinary comprehensive academic lymphedema program. Furthermore, lessons learned from our experience building a successful lymphedema program are discussed. RESULTS: Building a comprehensive academic lymphedema program requires institutional support and engagement of stakeholders to establish the necessary infrastructure for comprehensive patient care. This includes the infrastructure for outpatient clinical assessment, diagnostic investigations, radiological imaging, collection of outcomes metrics, non-surgical treatment delivered by lymphedema-specialist therapists, surgical procedures using specialized equipment, and integration of an outpatient framework for comprehensive patient evaluation during follow-up at standardized time intervals. CONCLUSIONS: This article examines our experience building a multidisciplinary comprehensive academic lymphedema program and provides a structured roadmap to benefit others that are embarking on this mission.
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BACKGROUND: Oncoplastic breast-conserving surgery (OBCS) is most commonly performed using established or modified mastopexy/breast reduction techniques. Although the comparative complication profiles of Wise-pattern mastopexy/breast reduction techniques compared with vertical scar techniques are well understood, outcomes in the setting of OBCS are unknown. METHODS: A retrospective study was conducted of all patients that underwent OBCS using mastopexy/breast reduction techniques at a single center over a 6-year period. Patients who underwent Wise-pattern techniques were compared with those who underwent vertical scar techniques. Demographic, treatment, and outcomes data were collected. Descriptive statistics were used, and multivariate analysis was performed to evaluate the relationship between these multiple variables and complications. RESULTS: Of 413 eligible patients, 278 patients (67.3%) received a Wise-pattern technique and 135 (32.7%) underwent a vertical scar technique. The overall complication rate was significantly higher in the Wise-pattern than in the vertical scar group (30.6% vs 18.5%, respectively; P = 0.012), as was the major complication rate (11.9% vs 4.4%; P = 0.011) including need for additional surgery for complications (6.8% vs 1.5%; P = 0.029). Complications resulted in a delay to any adjuvant therapy in 20 patients (4.8%); however, the difference between the groups was not significant (6.1% for Wise pattern vs 2.2% for vertical scar; P = 0.098). In a multivariable logistic model, use of a Wise-pattern technique (odds ratio, 0.37 [95% confidence interval, 0.14-0.99]; P = 0.049) was a significant predictor of major complications. CONCLUSIONS: The Wise-pattern mastopexy/breast reduction OBCS technique was associated with a significantly higher complication and major complication rate than vertical scar techniques. The findings should be considered during choice of surgical technique in oncoplastic breast conservation.
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Neoplasias de la Mama , Mamoplastia , Neoplasias de la Mama/cirugía , Cicatriz/etiología , Humanos , Mastectomía Segmentaria , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Oncoplastic breast-conserving surgery expands the indications for breast conservation. When performed using modified mastopexy/breast reduction techniques, the optimal timing of the contralateral symmetrizing mastopexy/breast reduction remains unclear. This study examined the effect of the timing of symmetrizing mastopexy/breast reduction on oncoplastic breast-conserving surgery outcomes. METHODS: A retrospective study was conducted of all patients who underwent oncoplastic breast-conserving surgery using mastopexy/breast reduction techniques at a single center from 2010 to 2016. Patients who received synchronous (immediate) contralateral breast symmetrizing mastopexy were compared with those who underwent a delayed symmetrizing mastopexy procedure. Demographic, treatment, and outcome data were collected. Descriptive statistics were used and multivariate analysis was performed to evaluate the various relationships. RESULTS: There were 429 patients (713 breasts) included in the study; of these, 284 patients (568 breasts) underwent oncoplastic breast-conserving surgery involving mastopexy/breast reduction techniques and immediate symmetrizing mastopexy, and 145 patients underwent delayed contralateral symmetrizing mastopexy. The overall complication rate was similar between the immediate and delayed groups (25.4 percent versus 26.9 percent, respectively; p = 0.82), as was the major complication rate (10.6 percent versus 6.2 percent; p = 0.16). Complications resulted in a delay in adjuvant therapy in 18 patients (4.2 percent); in two patients (0.7 percent), this delay resulted from a complication in the contralateral symmetrizing mastopexy breast. Immediate contralateral symmetrizing mastopexy was not associated with increased risk of complications per breast (p = 0.82) or delay to adjuvant therapy (p = 0.6). CONCLUSION: Contralateral mastopexy/breast reduction for symmetry can be performed at the time of oncoplastic breast-conserving surgery in carefully selected patients without significantly increasing the risk of complications or delay to adjuvant radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Neoplasias de la Mama/cirugía , Mamoplastia/métodos , Mastectomía Segmentaria/efectos adversos , Complicaciones Posoperatorias/epidemiología , Tiempo de Tratamiento , Adulto , Anciano , Mama/anatomía & histología , Mama/cirugía , Estética , Femenino , Estudios de Seguimiento , Humanos , Mamoplastia/efectos adversos , Mastectomía Segmentaria/métodos , Persona de Mediana Edad , Satisfacción del Paciente , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Oncologic resections involving both the spine and chest wall commonly require immediate soft-tissue reconstruction. The authors hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone. METHODS: The authors performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft-tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine and those who required a composite resection involving the chest wall. RESULTS: One hundred patients were included. Composite resection patients had larger defects, as indicated by a greater incidence of multilevel vertebrectomies (70.2 percent versus 17 percent; p = 0.001). Thoracic spine patients were older (58.2 ± 10.4 years versus 48.6 ± 13.9 years; p < 0.001) and had a greater incidence of metastatic disease (88.7 percent versus 38.3 percent; p = 0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of composite resection subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (OR, 0.22; 95 percent CI, 0.05 to 0.81; p = 0.03). CONCLUSIONS: Despite the large defect size in composite resection patients, there was no increase in complications compared to thoracic spine patients. In composite resection patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
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Osteotomía/efectos adversos , Complicaciones Posoperatorias/epidemiología , Neoplasias de la Columna Vertebral/cirugía , Vértebras Torácicas/cirugía , Pared Torácica/cirugía , Toracoplastia/métodos , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteotomía/métodos , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Colgajos Quirúrgicos/trasplante , Toracoplastia/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Large chest wall resections can result in paradoxical chest wall movement leading to prolonged ventilator dependence and major respiratory impairment. The purpose of this study was to determine as to which factors are predictive or protective of complications in massive oncologic chest wall defect reconstructions. METHODS: A retrospective review of a prospectively maintained database of consecutive patients who underwent immediate reconstruction of massive thoracic oncologic defects (≥5 ribs) was performed. Univariate and multivariate logistic regression analyses identified risk factors. RESULTS: We identified 59 patients (median age, 53 years) with a mean follow-up of 36 months. Rib resections ranged from 5 to 10 ribs (defect area, 80-690 cm2). Sixty-two percent of the patients developed at least one postoperative complication. Superior/middle resections were associated with increased risk of general and pulmonary complications (71.4% vs. 35.3%; OR 4.54; pâ¯=â¯0.013). The 90-day mortality rate following massive chest wall resection and reconstruction was 8.5%. Two factors that were significantly associated with shorter overall survival time were preoperative XRT and preoperative chemotherapy (pâ¯=â¯0.021 and p < 0.001, respectively). CONCLUSIONS: Patients with massive oncological thoracic defects have a high rate of reconstructive complications, particularly pulmonary, leading to prolonged ventilator dependence. Superior resections were more likely to be associated with increased pulmonary and overall complications. The length of postoperative recovery was significantly associated with the size of the defect, and larger defects had prolonged hospital stays. Because of the large dimensions of chest wall defects, almost half of the cases required flap coverage to allow for appropriate defect closure. Understanding the unique demands of these rare but challenging cases is critically important in predicting patient outcomes.
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Procedimientos de Cirugía Plástica , Neoplasias Torácicas/cirugía , Pared Torácica/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/mortalidad , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , Neoplasias Torácicas/mortalidadRESUMEN
BACKGROUND: Management of chest wall defects after oncologic resection is challenging due to multifactorial etiologies. Traditionally, skeletal stabilization in chest wall reconstruction (CWR) was performed with synthetic prosthetic mesh. The authors hypothesized that CWR for oncologic resection defects with acellular dermal matrix (ADM) is associated with a lower incidence of complications than synthetic mesh. METHODS: Consecutive patients who underwent CWR using synthetic mesh (SM) or ADM at a single center were reviewed. Only oncologic defects involving resection of at least one rib and reconstruction with both mesh and overlying soft tissue flaps were included in this study. Patients' demographics, treatment factors, and outcomes were prospectively documented. The primary outcome measure was surgical-site complications (SSCs). The secondary outcomes were specific wound-healing events, cardiopulmonary complications, reoperation, and mortality. RESULTS: This study investigated 146 patients [95 (65.1%) with SM; 51 (34.9%) with ADM] who underwent resection and CWR of oncologic defects. The mean follow-up period was 29.3 months (range 6-109 months). The mean age was 51.5 years, and the mean size of the defect area was 173.8 cm2. The SM-CWR patients had a greater number of ribs resected (2.7 vs. 2.0 ribs; p = 0.006) but a similar incidence of sternal resections (29.5% vs. 23.5%; p = 0.591) compared with the ADM-CWR patients. The SM-CWR patients experienced significantly more SSCs (32.6% vs. 15.7%; p = 0.027) than the ADM-CWR patients. The two groups had similar rates of specific wound-healing complications. No differences in mortality or reoperations were observed. CONCLUSIONS: The ADM-CWR patients experienced fewer SSCs than the SM-CWR patients. Surgeons should consider selectively using ADM for CWR, particularly in patients at higher risk for SSCs.
Asunto(s)
Dermis Acelular , Pared Torácica , Humanos , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Procedimientos de Cirugía Plástica , Estudios Retrospectivos , Mallas Quirúrgicas , Pared Torácica/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Oncoplastic breast-conserving surgery (OBCS) broadens the indications for breast conservation. Neoadjuvant systemic chemotherapy (NAC) is used increasingly in the treatment of patients with early-stage and locally advanced breast cancer. This study aimed to evaluate the outcomes for patients who received NAC followed by OBCS. METHODS: A retrospective chart review was performed for all patients who underwent OBCS involving the mastopexy/breast-reduction technique, including synchronous mastopexy/breast reduction for symmetry, at the University of Texas MD Anderson Cancer Center between January 2010 and January 2016. Patients who had received NAC were compared with those who had undergone surgery first. Demographic, treatment, and outcomes data were collected. RESULTS: The study included 429 patients, corresponding to 713 breasts. Of these patients, 122, corresponding to 199 breasts, received NAC. The patients who received NAC were younger (p < 0.001) and had a more advanced cancer stage (p < 0.001). The overall complication rate per patient was 25.9%, with major complications occurring in 9.1% of the patients. After adjustment for risk factors, NAC was not shown to be associated with an increased risk of complications or delayed adjuvant radiation therapy (p = 0.37), irrespective of the chemotherapy regimen used or whether the interval between NAC and surgery was 4 weeks or longer. CONCLUSIONS: In a high-volume center, OBCS can be performed safely for carefully selected patients after NAC without an increased risk of complications or delayed adjuvant radiation therapy. An interval of at least 4 weeks between completion of NAC and surgery can be regarded as safe irrespective of the chemotherapy regimen used.