Delay techniques for nipple-sparing mastectomy: A systematic review.

BACKGROUND: Rare but serious complications of nipple-sparing mastectomy (NSM) include necrosis of the nipple-areolar complex (NAC) and mastectomy skin flaps. NAC and mastectomy flap delay procedures are novel techniques designed to avoid these complications and may be combined with retroareolar biopsy as a first-stage procedure. We performed a systematic review of the literature to evaluate various techniques for NAC and mastectomy flap delay. METHODS: PubMed and Cochrane databases were searched from January 1975 through April 15, 2016. The following search terms were used for both titles and key words: 'nipple sparing mastectomy' AND ('delay' OR 'stage' OR 'staged'). Two independent reviewers determined the study eligibility, only accepting studies involving patients who underwent a delay procedure prior to NSM and studies with objective results including specific outcomes of NAC and mastectomy flap necrosis. RESULTS: The literature search yielded 242 studies, of which five studies met the inclusion criteria, with a total of 101 patients. Various techniques for NSM delay have been described, all of which involve undermining the nipple and surrounding mastectomy skin to some degree. Partial NAC necrosis was reported in a total of 9 patients (8.9%). Mastectomy flap necrosis was reported in a total of 8 patients (7.9%). Three of five studies reported positive retroareolar biopsy findings in a total of 7 patients (6.9%). CONCLUSIONS: Delay procedures for NSM have a good safety profile and may be considered in patients at risk for NAC or mastectomy flap necrosis, such as patients with pre-existing breast scars, active smoking, prior radiation, or ptosis. These procedures have the added benefit of allowing a retroareolar biopsy to be sent for permanent sections prior to mastectomy, allowing the surgical team to plan for the removal of the NAC at the time of mastectomy if indicated and eliminating the risk of a false-negative result on frozen section analysis.

Fat Grafting for Gluteal Augmentation: A Systematic Review of the Literature and Meta-Analysis.

BACKGROUND: With the increasing demand for gluteal fat augmentation, reports of fatal complications have surfaced. Therefore, the authors proposed to analyze the published techniques and compare different protocols, to identify those of potential concern. METHODS: A systematic review of the literature was performed with a search of 21 terms on the PubMed, MEDLINE, Cochrane, and Scientific Electronic Library Online databases. Nineteen articles meeting our predetermined criteria were analyzed, and data from the different steps of the procedure were classified, allowing evaluation and comparison of techniques. Independent-samples t test and one-way analysis of variance were used for statistical analysis. RESULTS: Seventeen case series and two retrospective studies including 4105 patients were reviewed. Most articles were authored in Colombia, Mexico, and Brazil. Most procedures were performed on adult female patients under general anesthesia. Fat was harvested using a tumescent technique from the lower extremities and the back, with machine-vacuum suction. A mean of 400 ml of decanted lipoaspirate was injected into each gluteal region, mostly subcutaneously and intramuscularly with 60-ml syringes. Most patients rated their results as "excellent." The mean complication rate was 7 percent (6.7 percent minor, 0.32 percent major), with no significant relation to the planes of injection. CONCLUSIONS: Fat grafting is an effective and predictable way to remodel the gluteal region; however, the procedure is not without risks. Avoiding gluteal vessel damage may prevent most feared complications, such as fat embolism. Accurate analysis, systematization of the procedure, and reporting cases in the fat grafting registry may provide the foundation for optimization of outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of aesthetic breast reconstruction after skin-sparing or conventional mastectomy in patients receiving preoperative radiation therapy.

Many options exist for the surgical treatment of breast cancer in terms of tumor extirpation and reconstruction. Skin-sparing mastectomy (SSM) with immediate reconstruction offers patients a superior result, but this can be jeopardized by preoperative radiotherapy. We compared the outcomes of reconstruction after SSM or conventional mastectomy (CM) in the previously irradiated breast. We evaluated 41 patients over an 8-year period, who were divided into 3 categories: preoperative radiotherapy prior to SSM (n = 8), CM after preoperative radiation therapy (n = 9), and no chest wall irradiation prior to SSM (n = 20). The first group demonstrated significantly higher frequency of native flap compromise and capsular contracture formation than the other 2 groups.SSM with TRAM or latissimus with implant reconstruction is an esthetically optimal option for the treatment of patients without previous radiotherapy. However, for patients with preoperative chest wall radiation, TRAM flap reconstruction was superior to latissimus flap with implant after SSM.