The Oncological and Surgical Outcomes of Immediate Oncoplastic Breast Reconstruction With Contralateral Breast Adjustment.

BACKGROUND: Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety. OBJECTIVES: This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution. METHODS: The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires. RESULTS: Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%. CONCLUSIONS: The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer.

Early outcomes of osteofascial versus osteocutaneous fibula free flap mandibular reconstruction.

BACKGROUND: This study compares early outcomes of osteofascial fibula free flap (OF-FFF) with donor-site primary closure and osteocutaneous (OC) FFF with donor-site skin grafting in segmental mandibular reconstruction. METHODS: A retrospective chart review of FFF mandibular reconstruction patients (2006-2022) divided into OF-FFF and OC-FFF groups. Clinical data, operative parameters, and early postoperative outcomes (≤ 90 days) were analyzed. RESULTS: The study included 67 patients (39 OF-FFF, 28 OC-FFF). OF-FFF had significantly lower donor-site complications (12.8% vs. 53.6%, p < 0.001) and revision surgeries (7.7% vs. 35.7%, p = 0.004) compared to OC-FFF. Recipient-site (28.2% vs. 25%, p = 0.77) and flap (15.4% vs. 17.9%, p > 0.99) complications were comparable. CONCLUSIONS: OF-FFF mandibular reconstruction with donor-site primary closure is a safe and reliable technique associated with superior donor-site and comparable flap and recipient-site outcomes to OC-FFF, thus may be considered as a viable alternative to OC-FFF for selected patients.

Our Experience in Diagnosing and Treating Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T-cell lymphoma detected in association with textured implants. It presents as a fluid accumulation around the implant, usually years after the implantation. We present our experience in diagnosing and treating four patients with BIA-ALCL, each widely differing from the other. Data on patients' surgical history, relevant medical information, and findings on pathological slides were retrieved from their medical charts and retrospectively reviewed. Each of the four patients was diagnosed with BIA-ALCL, one after breast augmentation, one after breast reconstruction with an implant, one after breast reconstruction with a latissimus dorsi flap and implant, and the fourth after the removal of breast implants. The cases were presented to a multidisciplinary team and subsequently underwent surgery. All four are currently free of tumors, as established by a negative follow-up via positron emission tomography-computed tomography. Although the incidence of BIA-ALCL is rare, these cases emphasize the need to rule out the diagnosis of BIA-ALCL in patients with textured implants or a history of implanted textured devices who present with symptoms such as late seroma or peri-implant mass. This pathology is typically indolent and slow-growing and heightened awareness for an early diagnosis could lead to quicker intervention and enhanced patient management.

Comparing the efficacy of antimicrobial pocket-irrigation protocols in an in vivo breast implant infection model.

BACKGROUND: Breast implant infection and biofilm formation are major concerns in reconstructive and esthetic breast surgery, with significant medical and economic consequences. Staphylococcus is the common pathogen, with rapidly increasing rates of methicillin-resistant Staphylococcus aureus (MRSA). There is no consensus on prevention practices. This study compares the effect of several pocket irrigation and antibiotic prophylaxis regimens on implant colonization and biofilm formation in an established rat model of MRSA-infected silicone breast implants. METHODS: Silicone discs were inserted in a sub-pectoral pocket in 57 rats (114 implants). Implant infection was induced by injection of free planktonic MRSA into the surgical pocket. Rats were allocated to study groups treated by different antimicrobial protocols: pocket irrigation with vancomycin, povidone-iodine, or saline. Each group was divided into subgroups treated with or without additional peri-operative systemic vancomycin. Implant colonization or overt infection was assessed at post-operative day 14 both clinically and by cultures. RESULTS: Pocket irrigation with vancomycin prevented contamination in 87% of implants. Irrigation and systemic vancomycin prevented contamination in 100% of implants with no difference between a single preoperative dose and a 48-h regimen. Systemic vancomycin alone or irrigation with povidone-iodine alone resulted in 100% contamination rates. CONCLUSIONS: In this in vivo model, combination of systemic vancomycin with vancomycin pocket irrigation was the most effective regimen, preventing contamination in 100% of implants. Continuation of post-operative antibiotic treatment showed no added advantage.

Using Virtual Reality for Deep Inferior Epigastric Perforator Flap Preoperative Planning.

This study was designed to compare VR stereoscopical three-dimensional (3D) imaging with two-dimensional computed tomography angiography (CTA) images for evaluating the abdominal vascular anatomy before autologous breast reconstruction. Methods: This prospective case series feasibility study was conducted in two tertiary medical centers. Participants were women slated to undergo free transverse rectus abdominis muscle, unilateral or bilateral deep inferior epigastric perforator flap immediate breast reconstruction. Based on a routine CTA, a 3D VR model was generated. Before each procedure, the surgeons examined the CTA and then the VR model. Any new information provided by the VR imaging was submitted to a radiologist for confirmation before surgery. Following each procedure, the surgeons completed a questionnaire comparing the two methods. Results: Thirty women between 34 and 68 years of age were included in the study; except for one, all breast reconstructions were successful. The surgeons ranked VR higher than CTA in terms of better anatomical understanding and operative anatomical findings. In 72.4% of cases, VR models were rated having maximum similarity to reality, with no significant difference between the type of perforator anatomical course or complexity. In more than 70% of the cases, VR was considered to have contributed to determining the surgical approach. In four cases, VR imaging modified the surgical strategy, without any complications. Conclusions: VR imaging was well-accepted by the surgeons who commented on its importance and ease compared with the standard CTA presentation. Further studies are needed to determine whether VR should become an integral part of preoperative deep inferior epigastric perforator surgery planning.

Our Experience Using Round Nano-Surface Ergonomix Implants for Breast Reconstruction: A Single-Center Retrospective Study.

BACKGROUND: Round nano-surface Ergonomix (Motiva, Establishment Labs; Alajuela, Costa Rica) implants were developed to address concerns regarding capsular contracture and textured anatomical breasts implants. OBJECTIVES: The authors describe their early experience with Ergonomix implants in breast reconstruction. METHODS: The authors retrospectively reviewed the charts of 212 patients (321 breasts) who underwent breast reconstruction employing round nano-surface Ergonomix implants between June 2017 and December 2020. Patients were followed for at least 12 months postoperatively. Demographics, surgical data, and postoperative surgical outcomes were recorded. Postoperative physical well-being and satisfaction with the breasts and implant were evaluated with Breast-Q questionnaires. RESULTS: Of 211 patients, 75.4% had surgery due to cancer, and 24.6% underwent prophylactic surgery. Major complications occurred in 21 breasts (6.5%), of which 20 underwent revision operations. Reconstruction failed in 1 case (0.3%). Eleven breasts (3.4%) had minor complications. Immediate breast reconstruction, irradiated breasts, and smokers had higher rates of complications (P = 0.009, 0.02, 0.022, respectively). Rippling was more common in the pre-pectoral implant plane compared with sub-pectoral reconstruction (9% vs 1.2%, P = 0.001). Capsular contracture rate was 0.9% and occurred only in irradiated breasts. Implant malposition (inferiorly and laterally) occurred in 6.5% of the breasts, with no association between implant malposition and implant plane. Early follow-up demonstrated high patient satisfaction with the implant and breasts, and high scores in terms of patients' physical well-being. CONCLUSIONS: Breast reconstruction employing the round nano-surface Ergonomix implant yielded low complication rates and high patient satisfaction. The transition from macro-textured to nano-surface implants has operative implications requiring a learning curve and surgical adjustments.

Treatment Algorithm of Postsurgical Fat Necrosis of the Breast-Revisited.

Fat necrosis is a common complication of breast surgery, with the potential to cause both functional and aesthetic repercussions that can affect patient satisfaction. Although several fat necrosis classification systems have been proposed, fat necrosis management varies widely across institutions, requiring revisiting of existing treatment protocols. We evaluated the postoperative outcomes on 335 breasts following either breast reduction or reconstruction with deep inferior epigastric perforator (DIEP) flaps at our institution between 2016 and 2020, with particular attention to the development of fat necrosis and the need for subsequent surgical intervention. Fat necrosis was diagnosed in 36 (10.74%) breasts, of which 16 (44.4%) were surgically removed and 20 (55.5%) were conservatively managed. Time of fat necrosis diagnosis: early (≤one-month after breast surgery) or late (>1 month) was the only variable associated with surgical intervention. Fat necrosis management should be approached on a case-by-case basis. Whenever possible, conservative management with regular clinical and radiological follow-up, and patient reassurance, should be pursued even for large masses, in the absence of concomitant complications.

Patient Satisfaction and Surgical Outcome After Oncoplastic Reconstruction following Radical Lumpectomy Versus Standard Lumpectomy: A Retrospective Cohort Study.

Objective: Oncoplastic reconstruction (OR) enables widening of the indications for breast conserving therapy (BCT) and is redefining the limits of breast conservation. We examined the outcome and satisfaction of patients undergoing OR after radical lumpectomy (excision of more than 25% of the breast volume) and compared it to the outcome of women undergoing OR after standard lumpectomy. Materials and Methods: A retrospective, cohort study, including all patients undergoing OR after BCT between 2009 and 2018, was conducted. The ratio of volume of excision to breast volume was calculated using imaging studies. The study group included women that had more than 25% of their breast volume removed. The remainder formed the control group. Demographic characteristics, oncological treatment, and operation properties were collected. We compared post-operative complications, margin status and need for further surgery, as well as patient satisfaction, evaluated using the BREAST-Q Questionnaire. Results: One hundred and fifty women were included, of whom 24 (16%) comprised the study group with a mean breast volume reduction of 39%, while the remainder (mean volume reduction 8%) served as controls. Patient, tumor characteristics and treatment were comparable. There was a non-significant higher proportion of women in the radical group that underwent a second operation due to complications or positive margins [4/24 (16.7%) vs. 14/126 (11%), p = 0.4). Physical well-being was similar but satisfaction with breasts and with outcome was slightly lower for the study group. These differences did not reach statistical significance. Conclusion: Surgical outcome and patient satisfaction in women undergoing very extensive breast resections with OR are comparable to standard resections.

[BREAST CANCER-RELATED LYMPHEDEMA: INCIDENCE AND RISK FACTORS, PREVENTIVE MEASURES AND TREATMENTS].

INTRODUCTION: Lymphedema is a pathological condition in which intercellular protein-rich fluid accumulates and leads over time to inflammation, adipose tissue hypertrophy and fibrosis. Secondary lymphedema is caused by injury or blockage of the lymphatic system and the main cause in the Western world is the treatment of a variety of cancers, the main one being breast cancer. Chronic arm edema after breast cancer surgery is a common problem with an estimated incidence of 1 in 5 patients after breast cancer treatment. In this article we review the main risk factors, approaches to reducing the risk of developing lymphedema after treatment for breast cancer and existing treatment protocols for lymphedema including the surgical innovations in this field and our experience in these innovative surgical approaches. To date, 26 physiological surgeries have been performed at the Tel Aviv Medical Center using the microsurgical approach for treating lymphedema. These surgeries had no significant complications and the improvement was observed to be greater in the group of patients with secondary lymphedema. Lymphovenous anastomosis and vascularized lymph node transfer offer promising solutions for the treatment of breast cancer related lymphedema. The introduction of additional techniques and the refinement of these procedures will probably continue to improve the results in the future.

Breast Implant-associated Anaplastic Large Cell Lymphoma Diagnosis 6 Years After Implant Removal: A Case Report.

ABSTRACT: We present a case report of a 48-year-old woman with a late-onset seroma of her left breast, 6 years after removal of her textured breast implants. At that time, she also had a late-onset seroma of her left breast, and capsulectomy was performed along with removal of the implants. The current late seroma presentation, which followed 6 years of uneventful healing, was treated with en bloc excision of the encapsulated seroma. Pathology results were concordant with locally invasive anaplastic large cell lymphoma (ALCL). Review of her previous seroma cytology from 6 years ago was performed given the current updated guideline standards on breast implant-associated ALCL (BIA-ALCL). Evidence of BIA-ALCL confirmed the patient had the diagnosis 6 years ago. The disease persisted and remained indolent for 6 years and manifested clinically as a late seroma of the left breast. This case report emphasizes the high degree of suspicion that is required in late seroma cases involving textured breast implants or a history of textured breast implants, along with the need for en bloc capsulectomy as a primary treatment for diagnosed BIA-ALCL to avoid incomplete capsulectomy and recurrence of the disease.

Management of Symptomatic Patients with Textured Implants.

SUMMARY: Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance.

Postirradiation Capsular Contracture in Implant-Based Breast Reconstruction: Management and Outcome.

BACKGROUND: Implant-based breast reconstruction is commonly avoided in the setting of radiation therapy, mainly because of risks of capsular contracture. Nevertheless, as breast reconstruction is becoming more available, more patients undergo both implant-based breast reconstruction and radiotherapy. The dilemma is how to manage capsular contracture if it does occur. The goal of this study was to examine the outcome of patients with implant-based breast reconstruction who developed postirradiation capsular contracture and were treated with capsulotomy or capsulectomy, with or without fat grafting. METHODS: The authors reviewed charts of patients who developed capsular contracture following alloplastic breast reconstruction followed by radiation therapy, between 2008 and 2018. The surgical treatment methods for capsular contracture were evaluated along with their outcomes. A follow-up of at least 1 year was required. RESULTS: Forty-eight breasts with postirradiation capsular contracture underwent surgical implant exchange with capsular release, of which 15 had combined fat grafting and 33 did not. Overall, 35 breasts (72.9 percent) showed long-term resolution of capsular contracture; 24 underwent a single procedure and 11 required an additional fat grafting procedure. Some patients [six breasts (12.5 percent)] were offered a consecutive round of fat grafting, and some [seven breasts (14.5 percent)] were offered autologous reconstruction because of lack of improvement. Fat grafting increased the success rate by more than 30 percent when it was initially and consecutively used. CONCLUSIONS: Postirradiation capsular contracture may be treated successfully by secondary procedures, sustaining implant-based breast reconstruction in over 70 percent of breasts. Fat grafting may elevate resolution rates even further, to 86 percent. Larger prospective studies are required to validate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Superiomedial Pedicle Breast Reduction for Gigantic Breast Hypertrophy: Experience in 341 Breasts and Suggested Safety Modifications.

BACKGROUND: Reduction mammoplasty in patients with gigantic breast hypertrophy runs a high risk of complication. Traditionally, inferior pedicle reductions or free nipple grafting techniques have been recommended for gigantic breasts on the basis of measurements and expected resection weights. The superiomedial pedicle (SMP) technique has been less commonly used, due to concerns of vascular inadequacy. This study examines the outcomes of SMP in large reductions and outlines suggested modifications for enhanced safety. METHODS: This is a retrospective review of all patients who underwent SMP breast reduction in our institution between 2005 and 2016. Included are cases with resection weights greater than 800 g. RESULTS: A total of 173 patients with 341 breasts were included. Mean sternal notch to nipple (SNN) distance was mean 35.0 ± 6.6 cm (range 23-44.5) on the left and 34.9 ± 6.6 cm (range 18-46) on the right. Mean resection weight was 1152.2 ± 368.6 g (range 810-2926) on the left and 1159.4 ± 326.6 g (range 800-2528) on the right. The total complication rate was 22.7%. Minor complications occurred in 63 (18.6%) breasts. Major complications occurred in 12 (4.1%) breasts. NAC congestion and partial necrosis occurred in 1.8% and total NAC necrosis in 0.9%. CONCLUSION: The SMP reduction technique is a safe option for gigantic breast reduction with comparable complication rates to other techniques. Preoperative measurements or resection weights are not reliable risk factors alone. High tissue density may be a significant risk factor. High-risk breasts mandate surgical planning and should be tailored to include technical modifications as described. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

[FACIAL NERVE PARALYSIS - THERAPEUTIC APPROACH, FACIAL REANIMATION AND ADJUNCTIVE TREATMENT].

INTRODUCTION: Paralysis of the facial mimetic muscles causes loss of voluntary and non-voluntary muscle function, as well as facial tone. This is a devastating condition with profound functional, aesthetic and psychological consequences. Etiologies include congenital paralysis and acquired paralysis following viral infection, trauma, head and neck tumors, iatrogenic damage and more. Clinical presentation includes ocular symptoms (dry eye, epiphora, corneal irritation), nasal symptoms (nasal obstruction) and oral symptoms (drooling and speech disturbances). Reconstruction of facial nerve function is based on renewing the neural input to the paralyzed face in parallel with transferring a functioning muscle. The gold standard in long term facial paralysis reanimation includes a two-stage procedure that involves cross-face nerve grafting and later on a free gracilis muscle transfer. This method allows reconstruction of a symmetric, spontaneous and voluntary smile. In cases when cross-face nerve grafting is impossible, a free-gracilis muscle transfer is performed with neural coaptation to another cranial nerve, most commonly the motor nerve to the masseter muscle (of the trigeminal nerve). Non-microsurgical methods for facial reanimation exist, however, nowadays they are rarely performed. In addition to the surgical reconstruction, other surgical and non-surgical procedures are performed for functional and aesthetic symmetrization purposes. These include fat injection to the face, botulinum toxin injection, oculoplastic procedures and more. In this article we describe our patient population with facial nerve paralysis, common facial reanimation procedures, considerations in choosing the appropriate reconstruction procedure and the general approach for treatment of facial paralysis in our multidisciplinary facial paralysis clinic.

How Common Is Breast Implant-Associated Anaplastic Large Cell Lymphoma? First Four Cases in Israel.

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (ALCL) is a rare type of non-Hodgkin's lymphoma that is found around breast implants. ALCL was discovered only two decades ago. In Israel we currently have four diagnosed cases (as of 2018). Until recently, the estimated incidence was 1:300,000 women with breast implants, while recent reports range from 1:3817 to 1:30,000. OBJECTIVES: To determine the occurrence of breast implant-ALCL in Israel. METHODS: We conducted a retrospective analysis of the four patients diagnosed with ALCL in Israel. Cytology was confirmed and the clinical data was collected. Based on the estimated number of women with breast implants in Israel, a calculation of the true incidence was completed. RESULTS: The incidence in Israel is significantly higher than the older incidence reports indicate. We estimated that the lifetime prevalence of the disease is 4:60,000 women with a textured breast implant, or 1:15,000 women with a textured breast implant in Israel. CONCLUSIONS: ALCL is not common. We support the claim that the prevalence is significantly higher than what was initially described. This finding has clinical and medicolegal implications that should be addressed accordingly.