Secondary Breast Reconstruction in Irradiated Patients: Prospective Trial Comparing DIEP to Brava Expansion and Fat Transplantation.

BACKGROUND: Autologous tissue reconstruction of the breast is preferable after irradiation. Fat transplantation is a possible alternative. The aim of this prospective trial was to compare outcomes of deep inferior epigastric perforator (DIEP) flaps to Brava expansion and fat grafting, after mastectomy and irradiation. METHODS: Patients were recruited among the candidates for delayed breast reconstruction after mastectomy and irradiation and were given the same information on both methods. Twenty-six patients underwent DIEP reconstruction, and 31 patients had multiple fat grafting sessions after Brava external tissue expansion. Outcomes were evaluated using the BREAST-Q questionnaire and the Telemark Breast Score. RESULTS: Twenty-four of 31 patients in the fat graft group completed the study. Six to nine operative sessions were required to gain a mean volume of about 490 mL. The mean total operative time was 11.5 hours. Four patients in this group developed a new primary or metastatic cancer disease during the study. Twenty-four of 26 patients in the DIEP group completed the study. The mean total operative time was 8 hours. The mean volume of the reconstructed breast was 523 mL. Telemark Breast Score values showed similar improvements in both groups at short terms of 3 months in the Brava group and 6 months in the DIEP group. CONCLUSIONS: Supplementary surgical procedures are often needed in breast reconstruction after mastectomy with irradiation using Brava external expansion and fat grafting. Even though the aesthetic results evaluated by surgeons were comparable, patients were more satisfied with outcomes after DIEP reconstruction compared with Brava expansion and fat grafting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Telemark Breast Score: a Valid Method for Evaluation of Outcome after Breast Surgery.

BACKGROUND: "Telemark Breast Score" (TBS) has been developed at Telemark Hospital in Norway for evaluation of results after breast surgery based on standardized patients' photographs taken as a part of daily routine. Its reliability has recently been tested and approved. The external validity of the TBS was assessed by matching its data against the internationally recognized Breast-Q (BQ) questionnaire as a further step to study the validity of this new tool. METHODS: The ideal distribution of breast volume is 45% of the total volume above and 55% below the nipple, and a 40° slope line at the upper pole. TBS makes the evaluation of these parameters of breast aesthetics more explicit. The method has been tested on photographs from 31 patients operated on for breast cancer with the Deep Inferior Perforator Flap. The evaluation was done by an independent experienced plastic surgeon earlier participating in the test-retests. The external validity of TBS was investigated against domains 1 and 3 of the BQ reconstruction module. The concordance between ratings was analyzed. RESULTS: Concordance between TBS items and BQ domain 1 items regarding patient satisfaction, and between TBS items and BQ domain 3 items regarding how the patient experienced the outcome of breast reconstruction was relatively high except for 6 comparisons where we could not statistically ensure that more pairs were concordant than discordant. A total of 178 comparisons appeared to be concordant. This means that for all other comparisons, there was a preponderance of pairs of concordant observations, which indicates that measurements from the 2 instruments follow each other. CONCLUSION: The present data indicate that the TBS can be recommended as a valid tool to professionals for assessment of the outcome after breast reconstruction.

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery.

BACKGROUND: Validated instruments for assessing results after breast surgery are sparse. The authors present here a method used for the past 10 years at their institution for evaluation of outcome after breast-conserving surgery and microsurgical breast reconstruction. METHODS: The Telemark Breast Score is a method based on standard two-dimensional photographs assessing the outcome after breast surgery in terms of volume, shape, and symmetry. Three panels comprising two plastic surgeons, two breast surgeons, and two nurses tested the Telemark Breast Score on 346 patients who underwent breast-conserving surgery for cancer and 31 other patients who underwent deep inferior epigastric perforator flap reconstruction. All patients were assessed at least 1 year after their operation. Consistency of agreement between and within the panels was studied. RESULTS: Interobserver and intraobserver reliability was good after consensus discussion. Good rating stability was shown using test-retest measurements. CONCLUSION: The Telemark Breast Score is an inexpensive, statistically reliable method and can be applied for quality control after breast surgery. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Survival and Inflammatory Response in Adipose-derived Mesenchymal Stem Cell-enriched Mouse Fat Grafts.

BACKGROUND: Adipose tissue-derived mesenchymal stem cells (ATMSCs) are currently used in grafting procedures in a number of clinical trials. The reconstructive role of such cells in fat graft enrichment is largely unclear. This study was undertaken to assess survival and inflammatory response in fat grafts enriched with ATMSCs in mice. METHODS: ATMSC-enriched adipose tissue was grafted subcutaneously in a clinically relevant manner in mice, and survival and inflammatory response were determined by bioluminescence imaging of transgenic tissue constitutively expressing luciferase or driven by inflammation in wild-type animals. RESULTS: Only a minor fraction of ATMSCs transplanted subcutaneously were found to survive long term, yet fat grafts enriched with ATMSCs showed improved survival for a limited period, compared with no enrichment. NF-κB activity was transiently increased in ATMSC-enriched grafts, and the grafts responded adequately to a proinflammatory stimulus. In one animal, cells originating from the subcutaneous graft were found at a site of inflammation distant from the site of engraftment. CONCLUSION: ATMSCs display limited subcutaneous survival. Still, ATMSC enrichment may improve the outcome of adipose tissue grafting procedures by facilitating short-term graft survival and adequate inflammatory responses. Migration of cells from grafted adipose tissue requires further investigation.

[Breast reconstruction following mastectomy]. / Brystrekonstruksjon etter mastektomi.

BACKGROUND: Breast cancer is the most common cancer in women, many of whom feel less feminine after the loss of a breast. Breast reconstruction can strengthen their self image, hence it is an excellent treatment option for those who have had a mastectomy. MATERIAL AND METHODS: This review is based on information retrieved from Medline and on clinical experience. We have also asked all departments of plastic surgery in Norway which methods of breast reconstruction they are using. RESULTS AND INTERPRETATION: Breast reconstruction following mastectomy is performed by plastic surgeons and if necessary in cooperation with breast surgeons. The missing breast can be reconstructed with an implant, autologous tissue or by combining the two methods. Many years of experience have resulted in high standards within reconstructive breast surgery. In Norway breast reconstruction is performed in every department of plastic surgery.

[Keloid and hypertrophic scars]. / Keloid og hypertrofisk arrdanning.

BACKGROUND: Keloid and hypertrophic scars develop most frequently in wounds with high skin tension and especially on the upper truncus. Both are characterized by an excessive dysfunctional collagen metabolism. MATERIAL AND METHODS: The article presents data from research in current literature and discuss the treatment of keloid and hypertrophic scars. RESULTS AND INTERPRETATION: Patients that are undergoing elective surgery should be handled with surgical techniques that reduce wound closing tension. Patients who are at high-risk or show excessive scar development should follow standard treatment. First-line therapy is silicone sheeting and/or pressure. In case of minimal response, steroid injections should be started after two months. The patient must be re-evaluated for a surgical approach combined with conservative treatment if the result is unsatisfactory after 12 months.