Laparoscopically harvested omental flap for immediate breast reconstruction: a retrospective single-center study of 300 cases.

BACKGROUND: The laparoscopically harvested omental flap (LHOF) has been used in partial or total breast reconstruction, but most studies on LHOF were case reports or small case series. However, the clinical feasibility and oncological safety of LHOF in oncoplastic breast surgery remains controversial. This study reported our experience applying LHOF for immediate breast reconstruction. METHODS: Between June 2018 and March 2022, 300 patients underwent oncoplastic breast surgery using LHOF at our institution. Their clinicopathological data, complications, cosmetic outcomes, and oncologic outcomes were evaluated. RESULTS: All patients underwent total breast reconstruction using LHOF after nipple-sparing mastectomy. The median operation time was 230 min (ranging from 155 to 375 min). The median operation time for harvesting the omental flap was 55 min (ranging from 40 to 105 min). The success rate of the laparoscopically harvested pedicled omental flap was over 99.0%. Median blood loss was 70 ml, ranging from 40 to 150 ml. The volume of the flap was insufficient in 102 patients (34.0%). The overall complication rate was 12.3%. Subcutaneous fluid in the breast area (7%) was the most common reconstruction-associated complication, but most cases were relieved spontaneously. The incidence rate of omental flap necrosis was 3.3%. LHOF-associated complications occurred in two cases, including one case of incisional hernia and one case of vascular injury. Cosmetic outcomes were satisfactory in 95.1% of patients on a four-point scale by three-panel assessment and 97.2% using the BCCT.core software. Two local and one systemic recurrence were observed during a median follow-up period of 32 months. CONCLUSIONS: The LHOF for immediate breast reconstruction is a safe and feasible method that involves minimal donor-site morbidity, satisfactory cosmetic outcomes, and promising oncologic safety.

Comparative Analysis of Recurrence-Free Survival and Mortality in Postmastectomy Patients: Insights From Multidecade, Multiinstitutional Propensity Score Matching.

INTRODUCTION: Disparities in postmastectomy reconstructive care are widely acknowledged. However, there is limited understanding regarding the impact of reconstructive services on cancer recurrence and breast cancer-related mortality. Therefore, this study aims to examine how patient-specific factors and breast reconstruction status influence recurrence-free survival and mortality rates in breast cancer patients. METHODS: Retrospective chart review was performed to collect data on patients who underwent mastectomy at 2 institutions within the New York-Presbyterian system from 1979 to 2019. Sociodemographic information, medical history, and the treatment approach were recorded. Propensity score matching, logistic regression, unpaired t test, and chi-square test were used for statistical analysis. RESULTS: Overall, cancer recurrence occurred in 6.62% (317) of patients, with 16.8% (803) overall mortality rate. For patients who had relapsed disease, completion of the reconstruction sequence was correlated with an earlier detection of cancer recurrence and improved survival odds (P < 0.05). Stratified analysis of the reconstruction group alone showed mortality benefit among patients who underwent free flap procedures (P < 0.05). CONCLUSION: Patients undergoing breast reconstruction after mastectomy are likely to have better access to follow-up care and improved interfacing with the healthcare system. This may increase the speed at which cancer recurrence is detected. This study highlights the need for consistent plastic surgery referral and continued monitoring by all members of the breast cancer care team for cancer recurrence among patients.

An Evolving Landscape: Return of Breast Sensation After Mastectomy Varies by Anatomic Region and Reconstructive Method.

PURPOSE: Loss of breast sensation after mastectomy has been well documented. Postoperative reinnervation of the breast is influenced by factors including reconstructive technique, patient comorbidities, and adjuvant treatment. However, little attention has been paid to the differences in sensation across regions of the breast and the impact of reconstructive method on these regional differences over time. METHODS: Patients undergoing nipple-sparing mastectomy with immediate autologous or alloplastic reconstruction were prospectively followed. Neurosensory testing was performed in 9 breast regions using a pressure-specified sensory device. Patients were stratified by reconstructive technique, and regional sensation was compared at different preoperative and postoperative time points using Student t tests. RESULTS: One hundred ninety-two patients were included; 106 underwent autologous reconstruction via neurotized deep inferior epigastric artery perforator flap, and 86 underwent 2-stage alloplastic reconstruction. Preoperative sensation thresholds did not differ between reconstructive cohorts in any region and averaged 18.1 g/mm2. In the first year after mastectomy, decreased sensation was most pronounced in the inner breast regions and at the nipple areolar complex (NAC) in both reconstructive cohorts. At 4 years postoperatively, sensation increased the most at the NAC in the alloplastic cohort (34.0 g/mm2 decrease) and at the outer lateral region in the autologous cohort (30.4 g/mm2 threshold decrease). The autologous cohort experienced improved sensation compared with the alloplastic cohort in 5 of 9 regions at 1 year postoperatively, and in 7 of 9 regions at 4 years postoperatively; notably, only sensation at the outer superior and outer medial regions did not differ significantly between cohorts at 4 years postoperatively. CONCLUSIONS: Although patients undergoing breast reconstruction experience increased breast sensation over time, the return of sensation is influenced by type of reconstruction and anatomic region. Regions closer to and at the NAC experience the greatest loss of sensation after mastectomy, although the NAC itself undergoes the most sensation recovery of any breast region in those with alloplastic reconstruction.Autologous reconstruction via a neurotized deep inferior epigastric artery perforator flap results in increased return of sensation compared with alloplastic reconstruction, particularly in the inferior and lateral quadrants of the breast.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND: The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. METHODS: A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. RESULTS: Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). CONCLUSIONS: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Simultaneous Free Flap Breast Reconstruction Combined With Contralateral Mastopexy or Breast Reduction: A Propensity-Matched National Surgical Quality Improvement Program Study on Postoperative Outcomes.

BACKGROUND: Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can increase patient satisfaction and minimize the need for a second procedure. Surgeon concerns of increases in operative time, postoperative complications, and final breast symmetry may decrease the likelihood of these procedures being done concurrently. This study analyzed postoperative outcomes of simultaneous contralateral mastopexy or breast reduction with free flap breast reconstruction. METHODS: By using the American College of Surgeons National Surgical Quality Improvement Program database (2010-2020), we analyzed 2 patient cohorts undergoing (A) free flap breast reconstruction only and (B) free flap breast reconstruction combined with contralateral mastopexy or breast reduction. The preoperative variables assessed included demographic data, comorbidities, and perioperative data. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 602 free flap breast reconstruction patients and 621 with concurrent contralateral operation patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. RESULTS: We identified 11,308 cases who underwent microsurgical free flap breast reconstruction from the American College of Surgeons National Surgical Quality Improvement Program database from the beginning of 2010 to the end of 2020. A total of 621 patients underwent a free flap breast reconstruction combined with contralateral mastopexy or breast reduction. After propensity score matching, there were no significant differences in patient characteristics, perioperative variables or postoperative medical complications between the 2 cohorts. CONCLUSIONS: Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can be performed safely and effectively without an increase in postoperative complication rates. This can improve surgeon competence in offering this combination of procedures as an option to breast cancer survivors, leading to better patient outcomes in terms of symmetrical and aesthetically pleasing results, reduced costs, and elimination of the need for a second operation.

Disparities in Breast Reconstruction: An Analysis of Treatment Choices.

BACKGROUND: Breast reconstruction methods vary based on factors such as medical history, breast size, and personal preferences. However, disparities in healthcare exist, and the role race plays in accessing to different reconstruction methods is unclear. This study aimed to investigate the influence of race and/or ethnicity on the type of breast reconstruction chosen. METHODS: This retrospective cohort study analyzed the University of Pittsburgh Medical Center Magee Women's Hospital database, including patients who underwent breast cancer surgery from 2011 to 2022. Multivariate analysis examined race, reconstruction, and reconstruction type (P < 0.05). RESULTS: The database included 13,260 women with breast cancer; of whom 1763 underwent breast reconstruction. We found that 91.8% of patients were White, 6.8% Black, and 1.24% were of other races (Asian, Chinese, Filipino, Vietnamese, unknown). Reconstruction types were 46.8% implant, 30.1% autologous, and 18.7% combined. Among Black patients, autologous 36.3%, implant 32.2%, and combined 26.4%. In White patients, autologous 29.5%, implant 48%, and combined 18.2%. Among other races, autologous 36.3%, implant 40.9%, and combined 22.7%. In patients who underwent breast reconstruction, 85.2% underwent unilateral and 14.7% of patients underwent bilateral. Among the patients who had bilateral reconstruction, 92.3% were White, 6.1% were Black, and 1.5% were of other ethnicities. CONCLUSIONS: Our analysis revealed differences in breast reconstruction methods. Autologous reconstruction was more common among Black patients, and implant-based reconstruction was more common among Whites and other races. Further research is needed to understand the cause of these variations.

Out-of-Pocket Costs and Payments in Autologous and Implant-Based Breast Reconstruction: A Nationwide Analysis.

BACKGROUND: Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction. METHODS: The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs. RESULTS: The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006). CONCLUSION: The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.

Level-2 Oncoplastic Surgical Techniques for Breast Cancer: A Preliminary Vietnamese Report.

Background: Breast cancer is the most common malignancy and remains the first cause of death related to cancer among Vietnamese women, with an incidence of 21,555 cases in 2020. Most breast cancer patients present with invasive disease and relatively large tumor sizes. While oncoplastic surgery (OPS) are commonly applied in Western countries, data on Asian population remains relatively limited. Objective: This study aims to assess the outcomes of level-2 oncoplastic techniques in breast-conserving surgeries at the Vietnam National Cancer Hospital. Methods: From January 2017 to June 2021, a cohort of 257 breast cancer patients who underwent breast-conserving surgery with OPS techniques were examined. Surgical complications, cosmetic outcome, recurrence and survival rates were assessed. Results: The mean age was 47.6±9.4 years, most patients had breast cup sizes B and C. The mean tumor size upon pathological examination was 2.00 ± 0.74 cm. Only 7 cases required reoperation, resulting in a mastectomy rate of 1.17%. The overall complication rate was low at 11.46%, with 9 cases (3.56%) experiencing delayed complications. Cosmetic results were rated as "excellent" in 20.6% and "good" in 60.5%, with a statistically significant difference. The rates of local recurrence, regional recurrence, and distant metastasis at five years were 2.78%, 1.19%, and 2.36%, respectively. Conclusion: The level 2 oncoplastic techniques had low complication rates, favorable oncological outcomes, and cosmetically satisfying results.

Analysis of flap thickness to breast projection ratio correlating to body mass index and age in east Asian women: Considerations in flap selection in breast reconstruction.

BACKGROUND: Several alternative flaps have been introduced and used for autologous breast reconstruction. However, as body fat distribution is different among patients, the donor of choice for sufficient breast projection varies between patients. METHODS: Patients who underwent autologous breast reconstruction from Jan 2018 to Sep 2022 were included. Age, body mass index (BMI), smoking history and hypertension, and diabetes occurrence were collected as baseline demographic data. Breast projection with five types of flap thickness was measured based on computed tomography angiography. Analysis was performed for five major autologous flaps for breast reconstruction. RESULTS: A total of 563 patients were included in the study. The mean age of the patients was 47.4 ± 7.9 (standard deviation; SD) years. The mean BMI of the patients was 24.0 ± 3.4 kg/m2. Only the correlation between flap thickness to breast projection ratio and age in the PAP flap illustrated statistical significance (p = .039), but the correlation coefficient was quite low (r = -0.087). Slim patients who had lower BMIs (under 25 kg/m2) had significantly higher sufficient flap thickness for breast reconstruction than patients with higher BMIs over 25 kg/m2 in the profunda artery perforator (PAP) flap (p < .001), the lumbar artery perforator (LAP) flap (p < .001), and the superior gluteal artery perforator (SGAP) flap (p < .001). CONCLUSIONS: The deep inferior epigastric perforator flap provided sufficient thickness and was not usually affected by age and BMI. The PAP, LAP, and SGAP flaps tended to maintain the thickness of the flap even when BMI decreased, so they are advantageous for reconstruction in slim patients. This study contributes evidence in consideration of flap selection in autologous breast reconstruction.

Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence.

For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Premastectomy Radiotherapy and Immediate Breast Reconstruction: A Randomized Clinical Trial.

Importance: Premastectomy radiotherapy (PreMRT) is a new treatment sequence to avoid the adverse effects of radiotherapy on the final breast reconstruction while achieving the benefits of immediate breast reconstruction (IMBR). Objective: To evaluate outcomes among patients who received PreMRT and regional nodal irradiation (RNI) followed by mastectomy and IMBR. Design, Setting, and Participants: This was a phase 2 single-center randomized clinical trial conducted between August 3, 2018, and August 2, 2022, evaluating the feasibility and safety of PreMRT and RNI (including internal mammary lymph nodes). Patients with cT0-T3, N0-N3b breast cancer and a recommendation for radiotherapy were eligible. Intervention: This trial evaluated outcomes after PreMRT followed by mastectomy and IMBR. Patients were randomized to receive either hypofractionated (40.05 Gy/15 fractions) or conventionally fractionated (50 Gy/25 fractions) RNI. Main Outcome and Measures: The primary outcome was reconstructive failure, defined as complete autologous flap loss. Demographic, treatment, and outcomes data were collected, and associations between multiple variables and outcomes were evaluated. Analysis was performed on an intent-to-treat basis. Results: Fifty patients were enrolled. Among 49 evaluable patients, the median age was 48 years (range, 31-72 years), and 46 patients (94%) received neoadjuvant systemic therapy. Twenty-five patients received 50 Gy in 25 fractions to the breast and 45 Gy in 25 fractions to regional nodes, and 24 patients received 40.05 Gy in 15 fractions to the breast and 37.5 Gy in 15 fractions to regional nodes, including internal mammary lymph nodes. Forty-eight patients underwent mastectomy with IMBR, at a median of 23 days (IQR, 20-28.5 days) after radiotherapy. Forty-one patients had microvascular autologous flap reconstruction, 5 underwent latissimus dorsi pedicled flap reconstruction, and 2 had tissue expander placement. There were no complete autologous flap losses, and 1 patient underwent tissue expander explantation. Eight of 48 patients (17%) had mastectomy skin flap necrosis of the treated breast, of whom 1 underwent reoperation. During follow-up (median, 29.7 months [range, 10.1-65.2 months]), there were no locoregional recurrences or distant metastasis. Conclusions and Relevance: This randomized clinical trial found PreMRT and RNI followed by mastectomy and microvascular autologous flap IMBR to be feasible and safe. Based on these results, a larger randomized clinical trial of hypofractionated vs conventionally fractionated PreMRT has been started (NCT05774678). Trial Registration: ClinicalTrials.gov Identifier: NCT02912312.

The Impact of Radiation on Nipple Symmetry After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: An Objective Analysis.

INTRODUCTION: Radiation therapy can adversely affect outcomes of implant-based breast reconstruction, potentially complicating procedures like nipple-sparing mastectomy (NSM), which is increasingly popular in breast cancer management. This study aims to evaluate the impact of radiation on nipple symmetry in patients undergoing bilateral NSM with implant-based reconstruction. METHODS: We conducted a retrospective analysis using data from an Emory University review board-approved database. This encompassed bilateral NSMs coupled with immediate implant-based reconstructions. The BCCT.core software was employed to objectively measure nipple asymmetry preoperatively and postoperatively. Metrics, such as Breast Retraction Assessment values, upper nipple retraction, lower breast contour, and nipple to midline (NML) discrepancies were quantified. The study included 80 patients with a minimum of 1 year of follow-up; among them, 15 received radiation therapy (RT) while 65 did not. RESULTS: The reconstructions were divided into tissue expander, used in 39 cases (48.8%), and direct-to-implant (DTI), employed in 41 cases (51.2%). The DTIs were further categorized based on the location of the implant: 22 subpectoral and 19 prepectoral. Radiation was applied to 15 breasts, distributed among prepectoral DTI (4), subpectoral DTI (6), and tissue expander (5). Breast Retraction Assessment scores significantly differed between the nonirradiated and irradiated groups (1.49 vs 2.64, P < 0.0004). Nipple to midline differences and Upper Nipple Retraction also significantly varied postradiation, especially when comparing subpectoral and prepectoral implant placements. CONCLUSIONS: Radiation therapy has a detrimental effect on nipple symmetry after bilateral NSM and implant-based reconstruction, with variations seen regardless of the implant's placement or the reconstructive technique utilized. Specifically, subpectoral reconstructions irradiated were prone to lateral nipple displacement, likely related to radiation-induced pectoralis muscle changes, while prepectoral irradiated reconstructions tended to have increased vertical displacement. These insights are crucial for patient education and surgical planning in the context of radiation and breast reconstruction.

Shifts in Reduction Mammaplasty Surgical Volumes With the Emergence of a Global Pandemic.

INTRODUCTION: The onset of the COVID-19 pandemic resulted in significant changes to the surgical caseload for various surgery departments across the United States. As medical institutions prioritized resources for the expected increase in patient volumes due to the SARS-CoV-2 viral infection, surgical departments saw a decrease in nonemergent and elective surgical procedures. Reduction mammoplasties, which are largely covered by insurance, are among the elective procedures that provide significant revenue to the hospital. This expected decline in procedures suggests a potential decline in revenue provided by the plastic surgery department of a hospital. The purpose of this study was to analyze the loss of revenue experienced by a single academic medical institution due to changes in breast reduction mammoplasty volumes during the COVID-19 pandemic. METHODS: Upon institutional review board approval, using the Augusta University Medical Center's Financial Billing Data, 373 patients who underwent bilateral reduction mammoplasty were queried. A time horizon of March 2019 to February 2022 was used to determine the pre- and post-COVID case load and charges that were incurred. Statistical analysis to compare the prior 12 months and after 24 months of COVID was conducted using 2 samples of equal variance t test and F test confirming equal variance. RESULTS: There was a statistically significant increase in the number of reduction mammoplasties performed per month from the year before the onset of COVID-19 (March 2020) to the 2 years after (6.6-11.4 per month, P = 0.0024). There was a statistically significant increase in the per-month charges from the AU Health system for reduction mammoplasties for the same period ($31,780.92-$52,113.34 per month, P = 0.0054). Although there was an increase in per-month revenue from reduction mammoplasties, this increase failed to reach statistical significance ($7,059.95-$10,423.51 per month, P = 0.064). CONCLUSIONS: The plastic surgery department saw a statistically significant increase in reduction mammoplasty cases and subsequent charges in the post-COVID cohort. These findings suggest that the emergence of a nationwide pandemic did not necessarily lead to a decrease in the volume of nonemergent surgical cases despite an expected decrease in caseload due to the need to reallocate hospital resources. On the contrary, there was an increase in caseload suggesting that there may be other factors contributing to patients' pursuance of reduction mammoplasty post-COVID including convenience, resulting from time off due to pandemic, meeting insurance-covered reduction criteria, and projected recovery time.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization.

ABSTRACT: We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study.

Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.

Symptomatic Calcifications after Mastectomy: A Rare Case Report with a Review of the Literature.

Introduction: Symptomatic calcifications of the breast or skin after breast cancer surgery and adjuvant radiotherapy are a rare entity, with only a few case reports published worldwide, reducing the patient's quality of life, whilst asymptomatic calcifications are a common finding on imaging methods. Case presentation: Herein, we present a rare case report of calcifications after mastectomy and post-mastectomy radiation therapy causing chronic inflammation with ulceration and fistula formation, with a two-step surgical approach consisting of excision with linear suture and excision with the reconstruction using a thoraco-epigastric flap. Conclusions: To our knowledge, this is the first publication proving the feasibility of this therapy in patients with symptomatic dystrophic calcifications of the skin or the breast. Moreover, the article provides an up-to-date review of published studies about symptomatic calcifications after breast cancer surgery and radiotherapy with a focus on the time of the clinical manifestation from the radiotherapy and the used radiotherapy scheme.

Current Global Trends in Prepectoral Breast Reconstruction.

Implant-based breast reconstruction (IBBR) is the most frequently performed procedure for breast reconstruction following mastectomy, which involves the surgical placement of breast implants. The approach to breast reconstruction can be divided into two main categories, namely prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR), based on the implant plan and placement technique. In recent years, there has been a significant surge in the popularity of prepectoral implant-based breast reconstruction, where the implants are positioned above the chest muscle, as opposed to beneath it in the subpectoral approach. However, despite this growing preference, there is a lack of comprehensive data regarding the national trends in the utilization of this technique, thus necessitating further investigation. This narrative review aims to ascertain the current global patterns linked to prepectoral breast reconstruction and elucidate the considerations surrounding patient and implant selection, reconstructive techniques, the utilization of meshes in prepectoral reconstruction, the ensuing outcomes and complications, the ramifications of radiotherapy, and the potential advantages of integrating fat infiltration into the implementation of this technique in breast reconstruction with a focus on published papers in last five years. Conclusion: Prepectoral breast reconstruction has emerged as an appropriate surgical option for individuals seeking breast reconstruction. This development can be attributed to the recent progress made in implant technology, which has significantly enhanced the outcomes of this procedure. Additionally, advancements in mastectomy techniques, autologous fat grafting, and the use of acellular dermal matrices (ADMs) have also played a vital role in improving the aesthetic results of prepectoral breast reconstruction. As a result, the significance and effectiveness of this technique in the field of breast reconstruction have been firmly established, making it an essential component of the overall armamentarium available to plastic surgeons for breast reconstruction purposes.

Oncologic safety of autologous fat grafting in primary breast reconstruction after mastectomy for cancer.

INTRODUCTION: Autologous fat transfer (AFT) is widely used to improve results of breast reconstructive surgery, but its safety is controversial. Our objective was to evaluate the oncologic safety of AFT in a homogeneous population of patients who underwent a total mastectomy with immediate reconstruction for breast cancer. METHODS: We performed a retrospective cohort study by identifying all patients who underwent immediate breast reconstruction after mastectomy for breast cancer from 2007 to 2015 in our center. A patient group with AFT performed in the 24 months after mastectomy was compared to a control group. RESULTS: Five hundred fifty cases were included, of whom 136 (24.7%) underwent at least one fat graft transfer. Median age was 51 years. Reconstruction was performed in 465 (84.5%) with an implant reconstruction. The median time from mastectomy to AFT was 13.8 months. The median follow up was 55.2 months. A total of 53 events were observed, including 10 (7.4%) in the AFT group and 43 (10.4%) in the control group. There was no difference in 5-year recurrence-free survival (RFS) between the groups. In the subgroup analysis, only lymph node involvement in patients who underwent AFT in the first 24 months after oncologic surgery appeared as a risk factor of recurrence. Among the 104 patients with lymph node involvement, 5-year RFS was 69.2% in patients with lipofilling vs 92.5% in patients without it (p = 0 0.0351). CONCLUSION: Performing early lipofilling in primary breast reconstruction after mastectomy for cancer seems to be oncologically safe. Lymph node involvement increases the risk of recurrence in this population.

Aesthetic and surgical outcomes of the modified matrix rotation technique for upper inner quadrant breast tumors: a case series.

In patients with breast cancer, oncoplastic breast-conserving surgery can achieve a good aesthetic outcome without compromising oncological outcomes. However, tumors located in the upper inner quadrant (UIQ) are challenging for surgeons because treatment gives rise to visible scars, glandular deformities, and deviation of the nipple-areolar complex. The present study was performed to analyze a modification of the matrix rotation technique for UIQ tumors and address the main drawback of this technique, which is a visible scar on the commonly exposed part of the breast. A prospective database of seven patients who presented with UIQ tumors and underwent the new modification technique was utilized for the analysis. All patients preferred the modified technique over the standard technique because of the absence of a scar in the UIQ (visible breast line). The postoperative patient-reported outcomes regarding breast shape, breast symmetry, and scar location were also satisfactory. No surgical complications were reported. This modified surgical technique results in a scarless UIQ and is an aesthetically acceptable procedure that can be considered for UIQ tumors.

Transverse division of the rectus abdominis muscle in deep inferior epigastric perforator flap elevation: A rescue technique to include more than one perforator.

BACKGROUND: It is important to include as many perforators as possible in order to enhance the vascularity of a deep inferior epigastric perforator (DIEP) flap. However, the rectus muscle must be transected transversely, which prevents suturing and can cause a defect along the same line as the muscle-sparing procedure. When harvesting the DIEP flap, no specific method was suggested to solve these muscle defects. We found that by transecting the rectus muscle transversely, the muscle could be sutured in the tendinous area more easily while maintaining muscle function. The purpose of this study is to confirm the long-term recovery of the rectus abdominis muscle through the volume change after DIEP flap using this tendinous transection and suture method. PATIENTS AND METHODS: A retrospective review of 28 patients who underwent unilateral breast reconstruction using a DIEP flap and the tendinous transection method for multiple perforators between May 2018 and April 2020 was conducted. The preoperative and postoperative volumes of the rectus abdominis muscle were estimated both the harvest and opposite sides. RESULTS: The preoperative and postoperative muscle volumes from the harvest side were 50.08 ± 8.71 cm3 and 48.56 ± 8.61 cm3, respectively. The volume difference was 1.522 cm3 decrease, which was not statistically significant (p = .070). The preoperative and postoperative muscle volumes from the opposite side were 50.50 ± 8.15 cm3 and 50.08 ± 8.18 cm3, respectively. The volume difference was 0.434 cm3 increase and was not statistically significant (p = .064). Postoperative volume changes in the rectus muscle were not statistically significant on either side. CONCLUSION: The tendinous transection method in the DIEP flap procedure did not significantly affect postoperative rectus muscle volume. Therefore, we expect this harvest method to allow DIEP flap reconstruction that includes multiple perforators and complete donor muscle recovery.