Direct-to-Implant, Prepectoral Breast Reconstruction: Geometric Breast Measurements and Changes at 2-Year Follow-Up.

BACKGROUND: Prepectoral breast reconstruction has recently experienced a resurgence in popularity. However, in direct-to-implant (DTI) reconstruction, there is no opportunity for capsular modifications before final implant insertion. Implant pocket and breast shape are thus maintained, initially, solely by the mastectomy skin flaps, and eventually, by attachments of the periprosthetic capsule. The present study aims to quantify changes in breast geometric measurements over time following DTI prepectoral breast reconstruction. METHODS: A retrospective chart review was performed for patients who underwent bilateral prepectoral DTI reconstruction performed by a single surgeon from June of 2016 to January of 2018. Patients followed for more than 2 years were included. Yearly standardized frontal photographs were analyzed, and nipple-to-midline, sternal notch-to-nipple, and midclavicle-to-lower pole measurements were obtained. Patient demographics, operative details, and complications were documented. RESULTS: A total of 72 breasts (38 women) undergoing direct-to-implant, prepectoral breast reconstruction were included in the final analysis. Acellular dermal matrix was used in 56 breasts only (78.9%) for anterior coverage. The average change in nipple-to-midline distance after 2 years decreased by 0.41 cm (range, -2.00 to 2.97 cm), sternal notch-to-nipple distance decreased by 0.62 cm (range, -4.98 to 5.4 cm), and midclavicle-to-lower pole distance decreased 0.10 cm superiorly (range, -6.07 to 3.6 cm). In breasts that underwent postmastectomy radiation therapy, the average changes were -0.08, -0.43, and -0.56 cm, respectively. No patient in this cohort had severe malposition requiring further surgery. CONCLUSIONS: The present study provides insight into geometric breast measurements following prepectoral breast reconstruction at 2-year follow-up. The minimal breast shape changes observed demonstrate the feasibility of prepectoral DTI reconstruction with or without the use of acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Topical Tranexamic Acid in Breast Reconstruction: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications. METHODS: This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded. RESULTS: Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients (56.6%). The use of topical TXA resulted in a mean drain output reduction of 30.5% (range, -83.6% to 26.6%). Drains on the TXA-treated breast were eligible for removal 1.4 days (range, 0 to 4 days) sooner than the control side. The TXA-treated group had three complications (5.67%) versus 15 (28.3%) in the control group (OR, 0.1920; P = 0.0129). Specifically, for operative hematomas, the TXA group had none (0%), versus three in the control group (5.7%) (OR, 0.1348; P = 0.18). CONCLUSIONS: Soaking the mastectomy bed with 3% topical TXA before implant insertion leads to a decrease in drain output and a decrease in complications. Topical administration of TXA represents an option to decrease complications in alloplastic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Complications of Capsulectomies: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database.

Background: Although plastic surgeons commonly perform capsulectomies for a variety of peri-prosthetic capsular conditions, the safety of capsulectomy remains unknown, and the literature lacks evidence describing its morbidity and complication rates for patients inquiring about its associated risks. Objectives: The present study aims to identify and define the complication rates associated with capsulectomies. Methods: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed between the years 2015 and 2018. All information pertaining to demographics, patient-related information, surgical indications, procedure-related information, outcomes, and complications were assessed. Results: The study identified 2231 cases of surgeon-reported capsulectomies; indications most commonly reported included capsular contracture (n = 638, 28.6%) and breast implant rupture (n = 403, 18.1%). In total, 141 patients (6.32%) were hospitalized for longer than 1 postoperative day (range, 2-28 days), while the overall complication rate was 3.0% (n = 67/2231 patients). Incidence of minor complications, representing superficial surgical site infections, was 0.8%, while the major complication rate was 2.24%. These included 7 cases of deep surgical site infections (0.3%), 19 organ space infections (0.9%), and 8 cases of wound dehiscence (0.4%). Eight patients developed sepsis (0.4%); 6 patients required transfusions (0.3%); 1 case of postoperative pneumonia and 1 myocardial infarction were also identified (n = 1 each, 0.0%). The overall reoperation and readmission rates were 2.0%, representing a readmission rate of 66% among patients with complications. Conclusions: The present study provides the first estimate of the incidence of complications associated with capsulectomies. Although the NSQIP database contains significant limitations, the data presented herein describe a complication profile that plastic surgeons can share with their patients during informed consent.

Aesthetic Limitations in Direct-to-Implant Prepectoral Breast Reconstruction.

BACKGROUND: Prepectoral direct-to-implant reconstruction has become an alternative to staged subpectoral expander-based reconstruction. Although the surgical safety of this technique has been shown, aesthetic limitations have not been well-described. This article reports aesthetic limitations and elucidates risk factors that may predispose patients toward developing unfavorable outcomes following direct-to-implant prepectoral breast reconstruction. METHODS: A retrospective chart review was performed, identifying patients who underwent prepectoral, direct-to-implant breast reconstruction from June of 2016 to June of 2019. Aesthetic limitations assessed included capsular contracture, rippling, implant malposition, and implant flipping. RESULTS: Two hundred twenty-four consecutive women representing 334 breasts underwent immediate reconstruction performed by a single plastic surgeon. A midlateral incision was used in 185 breasts (55.4 percent) and the Wise pattern in 95 breasts (28.8 percent). The mean follow-up time was 30.5 months (45.3 to 18.3 months). Significant capsular contracture (grade 3 to 4) was noted in 27 breasts (8.1 percent), implant flipping in four breasts (1.2 percent), implant displacement in five breasts (1.5 percent), major rippling in nine breasts (2.7 percent), and minor rippling in 17 breasts (5.1 percent). The use of acellular dermal matrix had no significant effect on the aesthetic outcomes. In comparing breasts with postmastectomy radiation, there was a significant difference in the presence of minor rippling and capsular contracture ( p < 0.05). CONCLUSIONS: This cohort represents the largest, single-surgeon, direct-to-implant prepectoral database in the literature. This report shows that aesthetic limitations were comparable to those seen with other forms of reconstruction. Complications did not differ in terms of acellular dermal matrix use. Certain factors can predispose patients to developing unfavorable aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Direct-to-Implant Prepectoral Breast Reconstruction: Patient-Reported Outcomes.

BACKGROUND: Direct-to-implant prepectoral breast reconstruction has recently experienced a resurgence in popularity because of its lower levels of postoperative pain and animation deformity. BREAST-Q, a well-validated patient-reported outcomes tool, was used to assess patient satisfaction and quality of life. The goal of this study was to assess patient-reported outcomes at 6-month and 1-year follow-up after direct-to-implant prepectoral breast reconstruction. METHODS: Sixty-nine consented adult patients undergoing a total of 110 direct-to-implant, prepectoral, postmastectomy breast reconstructions completed BREAST-Q questionnaires immediately preoperatively, and at 6 and 12 months thereafter. RESULTS: Mean breast satisfaction decreased nonsignificantly from 61.3 preoperatively to 58.6 at 12 months after reconstruction (p = 0.32). Psychosocial well-being improved nonsignificantly from 67.1 preoperatively to 71.1 at 12-month follow-up (p = 0.26). Physical well-being of the chest was insignificantly different, from 74.4 to 73.3 at 12-month follow-up (p = 0.62). Finally, sexual well-being similarly remained nonsignificantly changed from 60.2 preoperatively, to 59.1 at 12 months (p = 0.80). The use of acellular dermal matrix and postmastectomy radiotherapy did not have any significant effects on patient-reported outcomes. Through regression analysis, neoadjuvant chemotherapy, increased age, and incidence of rippling were found to negatively influence BREAST-Q results. CONCLUSIONS: Patients who underwent direct-to-implant prepectoral breast reconstruction demonstrated an overall satisfaction with their outcomes. As prepectoral breast reconstruction continues to advance and grow in popularity, patient-reported outcomes such as those presented in this study become of paramount importance in practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Skin-Reducing Mastectomy with Immediate Prepectoral Reconstruction: Surgical, Aesthetic, and Patient-Reported Outcomes with and without Dermal Matrices.

BACKGROUND: Prepectoral breast reconstruction is being increasingly popularized, largely because of technical advances. Patients with ptotic breasts and active cancer require mastectomies through a mastopexy excision pattern to achieve proper pocket control in a prepectoral single-stage operation. This article presents a single-surgeon experience with direct-to-implant, prepectoral reconstruction following skin-reducing mastectomies. METHODS: A retrospective chart review identified all patients undergoing prepectoral, direct-to-implant breast reconstruction following Wise-pattern mastopexy from June of 2016 to June of 2018. Surgical and aesthetic outcomes, including capsular contracture and revision surgery, were measured. The BREAST-Q was administered preoperatively, 6 months postoperatively, and 1 year postoperatively. RESULTS: Eighty-four patients (121 breasts) were included. A widely based inframammary fold adipodermal flap was used in all cases, with acellular dermal matrix used in 77 breasts (63.3 percent), free nipple grafts in 42 breasts (34.7 percent), and postmastectomy radiation therapy in 31 breasts (26.5 percent). Operative complications included nipple-areola complex necrosis in six (5.1 percent), hematoma in four (3.4 percent), seroma in four (3.4 percent), implant exposure in three (2.6 percent), and infection in one (0.9 percent). Minor complications included cellulitis in five (6.0 percent) and minor wound issues in five (4.3 percent). In aesthetic outcomes, only two nonirradiated breasts experienced a grade 3 to 4 or grade 4 capsular contracture requiring capsulectomy. Rippling was visible in four breasts (3.4 percent). The BREAST-Q showed good satisfaction with the technique, with no significant differences between nipple-areola complex techniques. CONCLUSIONS: This cohort represents the largest single-surgeon, Wise-pattern, direct-to-implant prepectoral database in the literature. This report showed that surgical and aesthetic complications did not differ in terms of acellular dermal matrix use. This technique has shown, through patient-reported outcomes, to yield good patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Analysis of Utility Assessment Scores to Objectify the Health Burden Caused by Breast Conservation Therapy.

BACKGROUND: Lumpectomy followed by radiation, known as breast conservation therapy (BCT), is a viable surgical treatment option for early-stage breast cancer. However, the current literature suggests that patients prefer mastectomy over BCT, likely due to the wide variety of postmastectomy reconstructive options. Our aim is to investigate the objective health burden of living with BCT to help surgeons gain a better understanding of patient treatment preferences. METHODS: Three validated health state utility tools were used to objectify the burden of living with post-BCT results: visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). A prospective sample of the general population and medical students were recruited, and their responses analyzed to attain these scores. RESULTS: Utility scores for living with BCT are VAS 0.81 ± 0.19, TTO 0.93 ± 0.10, and SG 0.92 ± 0.14. The TTO and SG suggest a willingness to trade 2.5 years of life years and an 8% chance of death undergoing reconstructive procedures to correct a BCT defect, respectively. Age, gender, race, education, and income were not statistically significant independent predictors for higher or lower utility scores. CONCLUSION: The impact of the health burden of BCT was ascertained using validated objective numeric utility scores. These indices demonstrate a willingness to trade less life years to undergo correction of a BCT defect than reconstruction following unilateral mastectomy. They can provide surgeons with the best objective understanding of patient preferences for shared decision-making in the management of breast cancer.

HISTORIQUE: La lumpectomie suivie d'une radiothérapie, ou conservation mammaire (CM), est un traitement chirurgical viable du cancer du sein précoce. Selon les publications, les patients préfèrent toutefois la mastectomie à la CM, probablement en raison du large éventail de possibilités de reconstructions après la mastectomie. Les chercheurs visent à explorer le fardeau objectif d'une vie avec une CM pour la santé, afin d'aider les chirurgiens à mieux comprendre les préférences des patientes en matière de traitement. MÉTHODOLOGIE: Les chercheurs ont utilisé trois outils utilitaires validés sur l'état de santé pour objectiver le fardeau de la vie après une CM : l'échelle visuelle analogique (ÉVA), l'arbitrage temporel (AT) et le pari standard (PS). Ils ont recruté un échantillon prospectif de la population générale et d'étudiants en médecine et ont analysé leurs réponses pour obtenir les scores. RÉSULTATS: Les scores d'utilité d'une vie avec une CM s'établissent comme suit : ÉVA 0,81 ± 0,19, AT 0,93 ± 0,10 et PS 0,92 ± 0,14. L'AT et le PS indiquent respectivement la volonté de perdre 2,5 années de vie et d'accroître le risque de décès de 8 % pendant les interventions de reconstruction pour corriger une anomalie de CM. L'âge, le genre, la race, l'instruction et le revenu n'étaient pas des prédicteurs indépendants statistiquement significatifs des scores d'utilité plus élevés ou plus faibles. CONCLUSION: Les chercheurs ont évalué les répercussions du fardeau de la CM sur la santé au moyen de scores d'utilité numériques validés. Ces indices démontrent la volonté de réduire le nombre d'années de vie pour corriger une anomalie de la CM plutôt qu'une reconstruction après une mastectomie unilatérale. Ils peuvent aider les chirurgiens à mieux comprendre les préférences des patientes pour parvenir à une décision commune en matière de prise en charge du cancer du sein.

Surgical and Oncologic Outcomes of Nipple-Sparing Mastectomy for a Cohort of Breast Cancer Patients, Including Cases with High-Risk Features.

BACKGROUND: Nipple-sparing mastectomy (NSM) remains controversial in patients with high-risk breast cancer. The objective of this study was to assess surgical and oncologic outcomes of NSM and to evaluate associations of outcomes with high-risk features. METHODS: A retrospective review was conducted of all NSM cases performed for breast cancer at 2 academic cancer centers between January 2013 and August 2018. RESULTS: Of the 175 patients who underwent NSM, 13 (7.4%) had locally advanced breast cancer (LABC), 52 (29.2%) had previous neoadjuvant chemotherapy, 21 (12.0%) had previous radiation therapy, 40 (22.8%) received postmastectomy radiation, 27 (15.4%) had de-epithelialized skin reduction, and 13 (7.4%) had free nipple grafting. The median duration of follow-up was 24 months. Nipple necrosis (4 cases; 2.2%) was associated with previous radiation (9.5%; P = .018), skin reduction (11.1%; P = .001), and nipple grafting (15.4%; P = .001). The nipple-areolar complex margin (NAC) was involved with invasive disease in 1 case. Local recurrence occurred in 8 cases (4.6%), with 1 in-NAC recurrence. Overall survival was 98.3%, and disease-free survival (DFS) was 88.6%. LABC was associated with worse DFS (hazard ratio, 4.28; P = .011), with all 4 recurrences being distant. CONCLUSIONS: Previous radiation, skin reduction, and nipple grafting are associated with an increased risk of NAC necrosis. None of these should be considered absolute contraindications, but patients should be counseled appropriately. Although LABC is associated with worse DFS, relapses are systemic. Longer follow-up is needed to establish oncologic safety in unselected breast cancer patients.

Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients.

BACKGROUND: The resurgence of prepectoral breast reconstruction has brought strict patient inclusion and exclusion criteria by numerous authors. This article provides an overview of a single surgeon's experience with 201 patients, 313 breasts using immediate, direct-to-implant prepectoral breast reconstruction. The article compares surgical outcomes of different patient cohorts to elucidate risk factors that may predispose patients toward developing complications. METHODS: A retrospective chart review was performed, identifying all patients who underwent prepectoral, direct-to-implant breast reconstruction from June of 2016 to June of 2018. RESULTS: A total of 201 patients representing 313 breasts were included. A midlateral incision was used in 157 breasts (50.2 percent), followed by a skin-reducing, Wise-pattern in 90 breasts (28.8 percent). Acellular dermal matrix was used in 243 breasts (77.6 percent), free nipple grafts were used in 39 breasts (12.5 percent), and postmastectomy radiation therapy was used in 58 breasts (18.5 percent). Complications requiring operative intervention occurred in 24 breasts (7.7 percent), and minor complications occurred in 23 breasts (7.3 percent). There were no significant differences in complication rates for (1) acellular dermal matrix use versus non-acellular dermal matrix use, (2) Wise-pattern versus other incision, or (3) postmastectomy radiotherapy (p > 0.05). CONCLUSIONS: This represents the largest single-surgeon, direct-to-implant prepectoral cohort in the literature. Surgical complications did not differ with acellular dermal matrix use, incision selection, and the use of postmastectomy radiation therapy. There may be an association between acellular dermal matrix use and major complications and radiotherapy with minor complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Acellular Dermal Matrix-sparing Direct-to-implant Prepectoral Breast Reconstruction: A Comparative Study Including Cost Analysis.

INTRODUCTION: Refined mastectomy techniques, the advent of new technologies and materials such as acellular dermal matrix (ADM), cohesive gel silicone implants, and intraoperative tissue perfusion analysis, have fueled a resurgence in prepectoral breast reconstruction. This article aims to compare an immediate direct-to-implant prepectoral ADM-sparing approach with the traditional subpectoral 2-stage immediate reconstruction. A cost analysis within a Canadian-run single-payer system is also presented. METHODS: A retrospective 2-group comparative chart review study was performed (June 2015-January 2017) to identify all patients who underwent prepectoral direct-to-implant breast reconstruction using an ADM-sparing technique. The comparison group consisted of patients having undergone traditional 2-stage subpectoral reconstruction with ADM. All countable variables were included in the cost analysis, which was performed in Canadian dollars. RESULTS: A total of 77 patients (116 reconstructed breasts) were included. Both the prepectoral and subpectoral groups were comparable in size, demographics including age, diabetic and smoking status, and receiving neoadjuvant chemotherapy and postmastectomy radiotherapy. Patients having undergone direct-to-implant prepectoral reconstruction benefited from fewer follow-up visits (3.8 vs 5.4, respectively) and from less complications (24.7% vs 35.6%, respectively) including animation deformity. In addition, direct-to-implant prepectoral reconstruction costs 25% less than the 2-stage subpectoral reconstruction when all associated costs were considered. CONCLUSION: Prepectoral implant placement avoids many of the disadvantages of the traditional 2 stage subpectoral reconstruction, including pectoralis muscle dissection, animation deformity, and multiple surgeries. As the first comparative cost analysis study on the subject, our ADM-sparing direct-to-implant prepectoral reconstruction method costs 25% less than the traditional 2-stage subpectoral reconstruction with a comparable complication profile.

Treatment of breast animation deformity: A systematic review.

INTRODUCTION: Animation deformity (AD) is a known complication of subpectoral implant placement and results from the contraction of the pectoralis major muscle with resultant movement of the underlying implant. This can lead to a poor cosmetic result, with the implant becoming distinctly visible postbreast reconstruction and augmentation. The prevalence and clinical significance of AD remain unclear. To date, there exists no published review outlining the treatment modalities for AD and their effectiveness. The objective of this study is to appraise the effectiveness of various treatment options through a systematic review of the literature. METHODS: The MEDLINE search tool was used to carry out a search of the PubMed. Two separate reviewers independently assessed the initial resultant papers based on strict inclusion and exclusion criteria. Factors evaluated included patient demographics, publication information, study design, number of patients, preventative/treatment technique, and type and size of implant. RESULTS: The search strategy yielded 504 articles, of which eight articles met all the inclusion criteria. This represents 214 individual breasts that underwent surgical correction for AD. Of the 214 included breasts, 151 were postmastectomy and reconstruction, while 63 were primary augmentation. Of the reconstructed breasts, 5.6% (n = 12) received radiation. Overall, interventions for treating AD were successful in all (n = 214) of the documented cases, with an overall complication rate of 11.6% (n = 25) reported in the studies after treatment. The techniques used to treat AD included subfascial plane change (n = 8), prepectoral (subglandular/subcutaneous) plane change (n = 187), and muscle-splitting techniques (n = 19). CONCLUSION: In conclusion, AD is likely an underestimated complication that is increasing in incidence with the growing number of breast implants being placed in the subpectoral plane. This review successfully identified the highly effective treatment modalities to combat AD. Patient characteristics and surgical technique must be tailored on a case-by-case basis to allow for optimum esthetic outcome given the substantial complication rate of these treatment modalities.

Laparoscopic Harvesting of Omental Flaps for Breast Reconstruction-A Review of the Literature and Outcome Analysis.

BACKGROUND: Evidence on the use of omental flaps for breast reconstruction in patients with breast cancer is lacking, and no published reviews report an outcome-based assessment of such flap. This review explores available data and evidence for change in complication rates following the shift toward laparoscopic harvesting. METHODS: We searched the databases Excerpta Medica database, MEDLINE, and PubMed from inception until December 2015 using search terms "omental flaps" and "breast reconstruction." Data extracted were patient characteristics, technique used, and outcome measures reported and were then analyzed based on the technique of harvesting. RESULTS: Twenty-two articles reporting 651 patients who underwent mastectomies and breast-conserving surgeries were included in this review. Most flaps, 537 (82.5%), were harvested by laparoscopy, and 626 (96.2%) of the flaps were pedicle flaps. The mean age was 47.7 years (standard deviation: 4.29), and mean follow-up was 38.1 months. There were 88 reported complications among 562 patients in 16 reports. The rate of any complication was calculated to be 15.0%, with a higher rate (29.1%) occurring with the open technique in comparison to laparoscopy (12.6%). The commonest complications were postoperative infection and breast firmness each reported in 2.22%. Most authors reported advantages of malleability and excellent aesthetic outcomes and disadvantages in terms of inability to estimate the volume of the flap and variability in size. CONCLUSION: Omentum use is safe and has advantages in breast reconstruction where other options are limited including a natural feeling and minimal donor site morbidity if harvested laparoscopically.

HISTORIQUE: Il y a peu de données probantes sur l'utilisation des lambeaux épiploïques pour la reconstruction mammaire de patientes atteintes d'un cancer du sein et aucune analyse publiée n'en évalue les résultats cliniques. La présente analyse évalue les données et les preuves disponibles sur les changements aux taux de complication après le passage aux prélèvements par laparoscopie. MÉTHODOLOGIE: Les auteurs ont procédé à des recherches dans les bases de données Excerpta Medica, MEDLINE et PubMed à compter de leur création jusqu'en décembre 2015 à l'aide des mot-clés omental flaps et breast reconstruction. Ils ont extrait les caractéristiques des patientes, la technique utilisée et les mesures des résultats cliniques déclarées, puis ont analysé les résultats en fonction de la technique de prélèvement privilégiée. RÉSULTATS: Les auteurs ont inclus dans la présente analyse 22 articles portant sur 651 patientes qui avaient subi une mastectomie et une chirurgie de conservation mammaire. Ainsi, 537 lambeaux (82,5 %) avaient été prélevés par laparoscopie, et 626 (96,2 %) étaient des lambeaux pédiculés. Les patientes avaient un âge moyen de 47,7 ans (ÉT 4,29 ans) et avaient été suivies pendant une période moyenne de 38,1 mois. Les auteurs ont relevé 88 complications déclarées chez 562 patientes de 16 études. Le taux de complication s'élevait à 15,0 %, mais était plus important (29,1 %) après la technique ouverte qu'après la laparoscopie (12,6 %). Une infection postopératoire et la fermeté des seins, toutes deux déclarées chez 2,22 % des patientes, étaient les principales complications. La plupart des auteurs soulignaient la malléabilité et l'excellent résultat esthétique comme avantages et l'incapacité d'évaluer le volume du lambeau et la variabilité des dimensions comme désavantages. CONCLUSION: L'utilisation du lambeau épiploïque est sécuritaire et comporte des avantages pour la reconstruction mammaire lorsque les autres possibilités sont limitées, y compris une sensation naturelle et une morbidité minime au siège du donneur lorsque le prélèvement est effectué par laparosocopie.

Transverse Cervical Artery: Consistent Anatomical Landmarks and Clinical Experience with Its Use as a Recipient Artery in Complex Head and Neck Reconstruction.

BACKGROUND: Many head and neck reconstructions occur in patients with extensive history of surgery or radiation treatment. This leads to complicated free flap reconstructions, especially in choosing recipient vessels in a "frozen neck." The transverse cervical artery is an optimal second-line recipient artery in head and neck reconstruction. METHODS: Seventy-two neck sides in 36 cadavers were dissected, looking for the transverse cervical artery and transverse cervical vein. Anatomical location of these vessels, their diameter, and length were documented. A retrospective analysis on 19 patients who had head and neck reconstruction using the transverse cervical artery as a recipient artery was undertaken as well with regard to outcome of procedures, reason for surgery, previous operations, and use of vein grafts during surgery. RESULTS: The transverse cervical artery was present in 72 of 72 of cadaveric specimens, and was infraclavicular in two of 72 specimens. Transverse cervical artery length ranged from 4.0 to 7.0 cm, and the mean diameter was 2.65 mm. The transverse cervical vein was present in 61 of 72 cadaveric specimens, the length ranged from 4.0 to 7.0 cm, and the mean diameter was 2.90 mm. The transverse cervical artery averaged 33 mm from midline, and branched off the thyrocervical trunk at an average 17 mm superior to the clavicle. Transverse cervical artery stenosis was markedly less in comparison with external carotid artery stenosis. In a 20-year clinical follow-up study, the transverse cervical artery was the recipient artery in 19 patients. A vein graft was used in one patient, and no flap loss occurred in any of the 19 patients. CONCLUSION: The transverse cervical artery is a reliable and robust option as a recipient artery in free flap head and neck reconstruction.

Pseudoangiomatous Stromal Hyperplasia: A Rare Cause of Idiopathic Gigantomastia.

Gigantomastia remains a rare clinical diagnosis with significant physical and psychological impacts on patients. We present the case of a 40-year-old woman with idiopathic breast enlargement. Further histological analysis of the breast tissue revealed pseudoangiomatous stromal hyperplasia. This is the first reported case of diffuse breast enlargement resulting from pseudoangiomatous stromal hyperplasia.

Mastopexy for breast ptosis: Utility outcomes of population preferences.

BACKGROUND: Breast ptosis can occur with aging, and after weight loss and breastfeeding. Mastopexy is a procedure used to modify the size, contour and elevation of sagging breasts without changing breast volume. To gain more knowledge on the health burden of living with breast ptosis requiring mastectomy, validated measures can be used to compare it with other health states. OBJECTIVE: To quantify the health state utility assessment of individuals living with breast ptosis who could benefit from a mastopexy procedure; and to determine whether utility scores vary according to participant demographics. METHODS: Utility assessments using a visual analogue scale (VAS), time trade-off (TTO) and standard gamble (SG) methods were used to obtain utility scores for breast ptosis, monocular blindness and binocular blindness from a sample of the general population and medical students. Linear regression and the Student's t test were used for statistical analysis; P<0.05 was considered to be statistically significant. RESULTS: Mean (± SD) measures for breast ptosis in the 107 volunteers (VAS: 0.80±0.14; TTO: 0.87±0.18; SG: 0.90±0.14) were significantly different (P<0.0001) from the corresponding measures for monocular blindness and binocular blindness. When compared with a sample of the general population, having a medical education demonstrated a statistically significant difference in being less likely to trade years of life and less likely to gamble risk of a procedure such as a mastopexy. Race and sex were not statistically significant independent predictors of risk acceptance. DISCUSSION: For the first time, the burden of living with breast ptosis requiring surgical intervention was determined using validated metrics (ie, VAS, TTO and SG). The health burden of living with breast ptosis was found to be comparable with that of breast hypertrophy, unilateral mastectomy, bilateral mastectomy, and cleft lip and palate. Furthermore, breast ptosis was considered to be closer to 'perfect health' than monocular blindness, binocular blindness, facial disfigurement requiring face transplantation surgery, unilateral facial paralysis and severe lower extremity lymphedema. CONCLUSIONS: Quantifying the health burden of living with breast ptosis requiring mastopexy indicated that is comparable with other breast-related conditions (breast hypertrophy and bilateral mastectomy). Numerical values have been assigned to this health state (VAS: 0.80±0.14; TTO: 0.87±0.18; and SG: 0.90±0.14), which can be used to form comparisons with the health burden of living with other disease states.

HISTORIQUE: La ptose mammaire découle du vieillissement, d'une perte de poids et de l'allaitement. La mastopexie est une intervention utilisée pour modifier la taille, le contour et l'élévation des seins affaissés sans en modifier le volume. Pour en savoir plus sur le fardeau d'une ptose mammaire exigeant une mastectomie sur la santé, on peut utiliser des mesures validées pour la comparer à d'autres états de santé. OBJECTIF: Quantifier l'évaluation utilitaire de l'état de santé des personnes qui présentent une ptose mammaire et qui profiteraient d'une mastopexie et déterminer si les scores d'utilité varient selon la démographie des participants. MÉTHODOLOGIE: Les chercheurs ont utilisé des évaluations utilitaires au moyen d'une échelle analogique visuelle (ÉAV), de l'arbitrage temporel (AT) et de la méthode du pari standard (PS) pour obtenir les scores d'utilité de la ptose mammaire, de la cécité monoculaire et de la cécité binoculaire d'un échantillon de la population générale et d'étudiants dans une profession médicale. La régression linéaire et le test t de Student ont été utilisés pour l'analyse statistique. P<0,05 était considéré comme statistiquement significatif. RÉSULTATS: Les mesures moyennes (± ÉT) de la ptose mammaire de 107 volontaires (ÉAV : 0,80±0,14, AT : 0,87±0,18, PS : 0,90±0,14) étaient statistiquement différentes (P<0,0001) des mesures correspondantes de cécité monoculaire et de cécité binoculaire. Par rapport à un échantillon en population, des connaissances médicales démontraient une différence statistiquement significative dans la moins grande susceptibilité à échanger des années de vie et à parier sur le risque d'une intervention comme la mastopexie. La race et le sexe n'étaient pas statistiquement significatifs, quels que soient les prédicteurs d'acceptation du risque. EXPOSÉ: Pour la première fois, le fardeau de la ptose mammaire exigeant une intervention chirurgicale a été établi au moyen de mesures validées (ÉAV, AT et PS). Ainsi, le fardeau de la ptose mammaire sur la santé était comparable à celui de l'hypertrophie mammaire, de la mastectomie unilatérale, de la mastectomie bilatérale et de la fente labiopalatine. Par ailleurs, la ptose mammaire était considérée comme plus près de la « santé parfaite ¼ que la cécité monoculaire, la cécité binoculaire, la défiguration exigeant une transplantation faciale, une paralysie faciale unilatérale et un lymphœdème des membres inférieurs. CONCLUSIONS: La quantification du fardeau de la ptose mammaire exigeant une mastopexie sur la santé est comparable à d'autres problèmes mammaires (hypertrophie mammaire et mastectomie bilatérale). Des valeurs numériques ont été attribuées à cet état de santé (ÉAV : 0,80±0,14, AT : 0,87±0,18 et PS : 0,90±0,14), et peuvent être utilisées pour former des comparaisons avec le fardeau d'autres états pathologiques sur la santé.

Nipple-areolar Complex Reconstruction following Postmastectomy Breast Reconstruction: A Comparative Utility Assessment Study.

BACKGROUND: Nipple-areola complex (NAC) reconstruction occurs toward the final stage of breast reconstruction; however, not all women follow through with these procedures. The goal of this study was to determine the impact of the health state burden of living with a reconstructed breast before NAC reconstruction. METHODS: A sample of the population and medical students at McGill University were recruited to establish the utility scores [visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG)] of living with an NAC deformity. Utility scores for monocular and binocular blindness were determined for validation and comparison. Linear regression and Student's t test were used for statistical analysis, and significance was set at P < 0.05. RESULTS: There were 103 prospective volunteers included. Utility scores (VAS, TTO, and SG) for NAC deformity were 0.84 ± 0.18, 0.92 ± 0.11, and 0.92 ± 0.11, respectively. Age, gender, and ethnicity were not statistically significant independent predictors of utility scores. Income thresholds of <$10,000 and >$10,000 revealed a statistically significant difference for VAS (P = 0.049) and SG (P = 0.015). Linear regression analysis showed that medical education was directly proportional to the SG and TTO scores (P < 0.05). CONCLUSIONS: The absence of NAC in a reconstructed breast can be objectively assessed using utility scores (VAS, 0.84 ± 0.18; TTO, 0.92 ± 0.11; SG, 0.92 ± 0.11). In comparison to prior reported conditions, the quality of life in patients choosing to undergo NAC reconstruction is similar to that of persons living with a nasal deformity or an aging neck requiring rejuvenation.

The utility of outcome studies in plastic surgery.

SUMMARY: Outcome studies help provide the evidence-based science rationalizing treatment end results that factor the experience of patients and the impact on society. They improve the recognition of the shortcoming in clinical practice and provide the foundation for the development of gold standard care. With such evidence, health care practitioners can develop evidence-based justification for treatments and offer patients with superior informed consent for their treatment options. Furthermore, health care and insurance agencies can recognize improved cost-benefit options in the purpose of disease prevention and alleviation of its impact on the patient and society. Health care outcomes are ultimately measured by the treatment of disease, the reduction of symptoms, the normalization of laboratory results and physical measures, saving a life, and patient satisfaction. In this review, we outline the tools available to measure outcomes in plastic surgery and subsequently allow the objective measurements of plastic surgical conditions. Six major outcome categories are discussed: (1) functional measures; (2) preference-based measures and utility outcome scores; (3) patient satisfaction; (4) health outcomes and time; (5) other tools: patient-reported outcome measurement information system, BREAST-Q, and Tracking Operations and Outcomes for Plastic Surgeons; and (6) cost-effectiveness analysis. We use breast hypertrophy requiring breast reduction as an example throughout this review as a representative plastic surgical condition with multiple treatments available.