[Oncologic safety of skin-sparing mastectomy followed by immediate breast reconstruction: rate and localization of recurrences, and impact of reconstruction techniques]. / Borkímélo (skin-sparing) mastectomia és azonnali emlorekonstrukció onkológiai biztonságossága a recidívaarány, recidívalokalizáció és a rekonstrukciós technika függvényében.

INTRODUCTION: Oncological safety of skin-sparing mastectomy followed by immediate breast reconstruction is widely debated. Current evidence is relatively poor since it is based mostly on short-term follow-up data of highly selected patient populations. AIM: Recurrence rates of a large cohort of non-selected patients, i. e. "all-comers" were analyzed during a 10-year follow up. METHODS: Patient records and follow-up data of 253 consecutive cases treated with of skin-sparing mastectomy and immediate breast reconstruction between 1995 and 2000 were studied. During this time period "all-comers" policy was applied, which meant that all patients treated with mastectomy were offered immediate breast reconstruction regardless of tumour stage. RESULTS: "All-comers" approach resulted in a large proportion of patients with more advanced disease. During the 112 months mean follow-up 8.2% locoregional, 2.9% local, 10.6% distal and 18.8% overall recurrence rates were detected. Breast cancer specific survival rate was 90.9%. Autologous breast reconstruction was applied more frequently in patients with higher tumour stage; therefore recurrence rate was higher compared to patients undergoing implant-based reconstruction. CONCLUSION: Based on these long-term follow-up data skin-sparing mastectomy combined with immediate breast reconstruction is an oncologically safe treatment option. Therefore, application of "all-comers" policy for breast cancer patients treated with skin-sparing mastectomy followed by immediate breast reconstruction is feasible.

[Intraoperative, postoperative and long-term oncosurgical safety of therapeutic mammaplasty]. / Terápiás emloplasztika intraoperatív, közvetlen posztoperatív és hosszú távú onkosebészeti biztonsága.

INTRODUCTION: (Pre)malignant lesion in the breast requiring mastectomy conventionally may be treated with breast conservation by using oncoplastic breast surgical techniques, which is called therapeutic mammaplasty. However, no reliable data has been published so far as regards the oncological safety of this method. AIM: The aim of the authors was to analyse the oncological safety of therapeutic mammaplasty in a series of patients. METHOD: 99 patients were treated with therapeutic mammaplasty and data were collected in a breast surgical database prospectively. Results were analysed with respect to intraoperative, postoperative and long-term oncological safety. RESULTS: Incomplete resection rate was 14.1%, which correlated with tumour size (p = 0.023), and multifocality (p = 0.012). Time between surgery (therapeutic mammaplasty) and chemotherapy was similar to time between conventional breast surgeries (wide excision, mastectomy, mastectomy with immediate reconstruction) and chemotherapy (mean 29-31 days; p<0.05). Overall recurrence rate was 6.1%, locoregional recurrence rate was 2% during 27 month (1-88) mean follow-up. CONCLUSIONS: Since literature data are based on relatively short follow-up and low patient number, it is highly important that all data on therapeutic mammaplasty is collected in a prospectively maintained breast surgical database in order to determine true recurrence after long-follow-up.

Fat grafting versus implant-based treatment of breast asymmetry, a single surgeon experience over 13 years: a paradigm shift?

BACKGROUND: Breast asymmetry can result from congenital or traumatic aetiologies. Breast implants, autologous fat grafting, or a combination of both of these techniques are commonly used to achieve symmetry. This study adds critical evaluation of long-term patient outcomes in a large study group, to evaluate pearls and pitfalls of these treatment modalities. METHODS: A prospectively maintained database of a single surgeon experience in breast asymmetry treatment over a 13-year period (2006-2018) was retrospectively analysed. Breast implant surgery and fat grafting to treat asymmetry were compared in terms of number of operations to achieve symmetry, complications, and overall patient satisfaction. RESULTS: Thirty-five patients underwent breast implant surgery, requiring an average 2.1±1.6 operations to achieve symmetry, with a major complication rate (requiring secondary procedures) of 26% (n=9). Again, 26% (n=9) were converted to lipofilling due to either implant removal or unsatisfactory results. Thirty (86%) patients underwent fat transfer monotherapy to achieve symmetry and no major complications were recorded. Nine percent (n=3) of these patients preceded to have additional implant surgery. CONCLUSIONS: Although implant-based reconstruction seemingly offers a quick single stage procedure, it is associated with significantly more revision procedures as a result of complications including capsular contracture, implant rupture and breast distortion. Fat grafting, despite requiring sequential operations to achieve initial symmetry, ultimately offers a more durable result and is associated with significantly fewer and more minor complications, while not increasing the total number of procedures required to achieve symmetry in the long term.

International development and implementation of a core measurement set for research and audit studies in implant-based breast reconstruction: a study protocol.

INTRODUCTION: Outcome reporting in research studies of breast reconstruction is inconsistent and lacks standardisation. The results of individual studies therefore cannot be meaningfully compared or combined limiting their value. A core outcome set (COS) has been developed to address these issues and identified 11 key outcomes to be measured and reported in all future research and audit studies in reconstructive breast surgery (RBS). A COS represents what key outcomes should be measured. The next step is to determine how and when this should be done. The aim of this study is to develop a core measurement set (CMS) for use in research and audit studies in implant-based breast reconstruction. METHODS AND ANALYSIS: The CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials initiative (COMET) and COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) group for the selection of outcome measurement instruments (OMIs) for relevant outcome domains included in the RBS COS. This will involve three phases with strategies to promote implementation as a final additional phase. The phases are (1) conceptual considerations in which the target population, procedures and settings are defined; (2) systematic reviews to identify existing clinical, patient-reported and cosmetic OMIs and, if appropriate, assess their quality using COSMIN methodology; (3) a modified Delphi process including sequential Delphi surveys involving approximately 100 healthcare professionals and a face to face consensus meeting to agree and ratify which outcome definitions and OMIs should be used and standardised time points for assessment; (4) strategies to promote dissemination and adoption of the CMS. ETHICS AND DISSEMINATION: Ethical approval has been granted by University of Bristol Faculty Research Ethics Committee FREC ID 60221. Dissemination strategies will include scientific meeting presentations and peer-reviewed journal publications. Implementation activities will include engagement with journal editors and funders to promote uptake and use of the CMS.

Functional recovery after bilateral extended autologous latissimus dorsi breast reconstruction: A prospective observational study.

BACKGROUND: The impact of unilateral extended autologous latissimus dorsi (EALD) flap harvest and axillary surgery on shoulder function has been well described, but the impact of bilateral EALD flap harvest has not been clearly defined nor is it clear whether reconstructions should be synchronous or staged. METHODS: In this prospective observational study, patients undergoing bilateral EALD breast reconstruction (February 2003-December 2009) completed the disability, arm, shoulder and hand (DASH) questionnaire preoperatively and at five post-operative timepoints. Intensive shoulder physiotherapy was offered to those whose DASH score was >30 at 6 weeks or >20 at 12 weeks post-operatively. RESULTS: Sixty patients underwent bilateral EALD flap breast reconstruction (51 synchronous, 9 metachronous). Patients with pre-existing shoulder pathology (n = 1) and those who failed to return any post-operative DASH questionnaire (n = 10) were excluded from initial DASH analysis. However, these eleven patients were included in a separate analysis as an intention-to-treat analysis. Statistical analysis was performed using non-parametric, Friedman test and multiple comparison model. Forty-nine patients' DASH scores were analysed. DASH score initially increased after surgery and then returned to functionally normal within 3-6 months (median DASH: preoperative = 1 vs 6 weeks post-operation = 26, p = <0.001; vs 3 months = 19, p = <0.001; vs 6 months = 13, p = <0.001); thereafter, the scores remained less than 12 (p = <0.001). Median DASH score after synchronous reconstruction was not higher than that after metachronous reconstructions, although the metachronous sample size was small. CONCLUSION: With appropriate patient selection and intensive physiotherapy, bilateral EALD breast reconstruction does not appear to cause significant long-term impairment of shoulder function, and patients can now be counselled about the likely timecourse of shoulder recovery. There seems no reason to stage bilateral reconstruction to reduce shoulder morbidity.

Chest resurfacing with a reverse abdominoplasty flap for invasive breast cancer recurrence.

We present a patient with recurrent breast cancer requiring massive resection of the upper chest. Management included a reverse abdominoplasty flap to resurface the anterior chest wall, with acceptable aesthetic outcomes, and adjuvant chemotherapy. RA is a simple and versatile coverage option in patients with high risk of disease recurrence.

Idiopathic neonatal ischemia in the upper limb: the role of the microsurgeon.

Idiopathic neonatal limb ischemia remains a rare occurrence. It is a devastating process that leads to complete or partial loss of affected limb or severe deformity. The main treatments over the years have been conservative and nonsurgical, such thrombolysis. Surgical treatment has traditionally been delayed until a line of demarcation is clear, at which time amputation of the limb proceeds. We present a case of idiopathic upper limb ischemia in a newborn, where it was clear that nonsurgical management would result in limb necrosis. A thrombus extended from the brachial bifurcation into both ulnar and radial arteries to the wrist. The plastic surgery team performed surgical decompression and microsurgical open thrombectomy to successfully reestablish the circulation to the affected hand. Eight months later, the child remains well. This is the first reported case in the literature where an idiopathic thrombus blocking the brachial, radial, and ulnar arteries is successfully treated microsurgically.

[Oncoplastic approach in breast cancer surgery--a new challenge for the future breast surgeon?]. / Onkoplasztikai szemlélet az emlorák sebészetében--új kihívás a jövo emlosebészeinek?

The future challenge of breast surgery, the so-called oncoplastic approach is reviewed in this article. The authors discuss the most frequently applied surgical techniques as well as their indications. Medline and pubmed search was carried out using the following keywords and cross-references: "oncoplastic breast surgery", "breast reconstruction", "breast conserving surgery" and "reduction mammoplasty". Original and review papers published in English language and their references were included. In the literature surprisingly, a large variety of breast oncoplastic surgical procedures has been described. Although reconstructions with local flaps are relatively easy procedures, proper indications for these are critical in order to improve cosmesis after breast conservation. Applications of pedicled flaps are technically more demanding, and only properly trained oncoplastic breast or plastic surgeons are able to provide the possibly best aesthetic outcome after mastectomy or breast conserving surgery. Finally, carrying out free flap reconstructions after mastectomy should be assigned exclusively to plastic surgeons qualified in microsurgical techniques, and not to surgical oncologists. As conclusions oncoplastic approach will be an integral element of the surgical treatment of breast cancer in the future. Breast oncoplastic training is an interdisciplinary task, which combines surgical oncological management of breast cancers with aesthetic/reconstructive breast surgery.

A population-based audit of surgical practice and outcomes of oncoplastic breast conservations in Scotland - An analysis of 589 patients.

INTRODUCTION: Current evidence for oncoplastic breast conservation (OBC) is based on single institutional series. Therefore, we carried out a population-based audit of OBC practice and outcomes in Scotland. METHODS: A predefined database of patients treated with OBC was completed retrospectively in all breast units practicing OBC in Scotland. RESULTS: 589 patients were included from 11 units. Patients were diagnosed between September 2005 and March 2017. High volume units performed a mean of 19.3 OBCs per year vs. low volume units who did 11.1 (p = 0.012). 23 different surgical techniques were used. High volume units offered a wider range of techniques (8-14) than low volume units (3-6) (p = 0.004). OBC was carried out as a joint operation involving a breast and a plastic surgeon in 389 patients. Immediate contralateral symmetrisation rate was significantly higher when OBC was performed as a joint operation (70.7% vs. not joint operations: 29.8%; p < 0.001). The incomplete excision rate was 10.4% and was significantly higher after surgery for invasive lobular carcinoma (18.9%; p = 0.0292), but was significantly lower after neoadjuvant chemotherapy (3%; p = 0.031). 9.2% of patients developed major complications requiring hospital admission. Overall the complication rate was significantly lower after neoadjuvant chemotherapy (p = 0.035). The 5 year local recurrence rate was 2.7%, which was higher after OBC for DCIS (8.3%) than invasive ductal cancer (1.6%; p = 0.026). 5-year disease-free survival was 91.7%, overall survival was 93.8%, and cancer-specific survival was 96.1%. CONCLUSION: This study demonstrated that measured outcomes of OBC in a population-based multi-centre setting can be comparable to the outcomes of large volume single centre series.

Six-year follow-up of patients treated with oncoplastic reduction mammoplasty: A cohort study.

BACKGROUND: Current evidence for the oncological safety of oncoplastic breast conservation is poor as it is based mostly on short-term follow-up data. Hence, we report long-term recurrence rates in patients treated with oncoplastic reduction mammoplasty (ORM). METHODS: A prospectively maintained database was searched to identify patients who underwent ORM between 2005 and 2010. A retrospective review of medical records was carried out, including patients with ductal carcinoma in situ and invasive breast cancer. RESULTS: Follow-up data from 65 consecutive patients with ORM were reviewed, of which 50 patients were eligible to measure long-term recurrence rates. The average weight of the resected tissue was 272 g altogether. The mean preoperative tumour size was 2.95 cm on imaging. 64% of patients had stage II - III cancers. Incomplete excision rate after ORM was 16.1%, completion mastectomy rate was 10.7%. During a median follow-up of 72 months, 2% local, 6% distant recurrence rates were detected. The breast cancer-specific survival rate was 96% per cent. CONCLUSIONS: Based on these long-term follow-up data, ORM is an oncologically safe treatment option.

Imaging Results Following Oncoplastic and Standard Breast Conserving Surgery.

BACKGROUND: Oncoplastic breast-conserving surgery (OBCS) requires more complex surgical techniques than standard wide local excision (WLE) and the postoperative complication rate may be higher. Since these can have an impact on postoperative imaging, we compared imaging and biopsy results after OBCS and WLE. METHODS: Findings for patients undergoing OBCS (n = 83) or standard WLE (n = 128) were compared. Numbers, indications and outcomes of mammograms, breast ultrasounds, magnetic resonance imaging scans and biopsies done within 2 years after surgery were analysed. RESULTS: OBCS was applied for more advanced malignancy. Significantly more patients required breast ultrasound after OBCS than WLE (20/71 vs. 17/116; p = 0.024). Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4 ultrasound results were found only in patients with OBCS (6/29 vs. 0/19; p = 0.034). Significantly more biopsies were required after OBCS (9/71 vs. 3/116; p = 0.006). New lumps or lumpiness were the commonest indications, and pathology confirmed fat necrosis in the majority (7/12). The rate of fat necrosis after OBCS was 18% on clinical examination (13/71), 15% with ultrasound (11/71) and 7% confirmed on pathology (5/71). CONCLUSION: Patients treated with OBCS require significantly more ultrasound scans and consequent biopsies than patients who underwent WLE. This is mainly due to fat necrosis developing after OBCS in the majority of cases.

Perforator flap breast reconstruction.

A perforator flap consists of skin and fat harvested from a donor site nourished by myocutaneous perforators while sparing the donor muscle for function and strength. This flap type has revolutionized microvascular free tissue transfer and the technique has been successfully applied to well-established donor sites for autologous breast reconstruction namely the lower abdomen, upper and lower buttock, the upper back, and the lateral thigh. Although these flaps are technically more demanding than conventional myocutaneous free flaps, their minimal impact on the donor site muscle function significantly reduces local morbidity, postoperative pain and hospital stay. Perforator flap breast reconstruction has an increased operating time because of the meticulous dissection of the perforators, the possible anatomical variation in their location and, once these are located, the difficulty in selecting suitable perforator(s) to base the flap on. Although it has been suggested that perforator flaps may have a higher incidence of fat necrosis and partial flap loss than conventional free myocutaneous flaps, this has not been borne out by clinical results. There is, however, a learning curve and careful patient selection is important. The role of perforator flap technique in breast reconstruction is evolving. While its indications are similar to those of free TRAM and gluteal flaps, it is clearly a better alternative to these. The choice of perforator flap depends on where the patient has the most abundant donor tissue and the surgeon's experience. These flaps may in the future become the standard of care in free flap breast reconstruction.

Triamcinolone reduces seroma re-accumulation in the extended latissimus dorsi donor site.

BACKGROUND: The incidence of donor site seroma after autologous latissimus dorsi (ALD) breast reconstruction is in the order of 70%. In the majority of cases the seroma recurs following an initial aspiration. We designed a double-blind randomised controlled trial to test the hypothesis that an intracavity injection of the anti-inflammatory corticosteroid triamcinolone would inhibit seroma re-accumulation. METHODS: We recruited 52 ALD breast reconstructions in 49 patients, of whom 41 involved immediate reconstruction and 11 delayed reconstruction. Patients exhibiting seromas at their first postoperative visit were randomised to receive either intracavity triamcinolone 80 mg (Group A, n=29) or saline (Group B, n=23), following seroma aspiration. We recorded the incidence of wound complications, total time (days) and number/volume of subsequent aspirations to dryness. RESULTS: Triamcinolone significantly reduced the need for any further aspiration (A=16/29, B=22/23), total number of aspirations (A: median=1, interquartile range=0-1; B: median=4, interquartile range=2-5; P<0.0001), total volume aspirated (A: median=30 ml, interquartile range=0-80; B: median=325 ml, interquartile range=199-550; P<0.0001), and total time to dryness (A: median=12 days, interquartile range 7-17; B: median=37 days, interquartile range 20-49; P<0.0001). The incidence of adjuvant chemotherapy (A=16/29, B=9/23) and radiotherapy (A=16/29, B=10/23) was similar, and there was no effect upon donor site complications (Group A=4/29, Group B=2/23, P=0.725). The mean follow-up time for patients in the steroid group was 264 days compared to 254 days for those in the placebo group. Steroid injections were well tolerated, and there were no infective complications. CONCLUSION: Following initial aspiration, intracavity injection of triamcinolone significantly reduced seroma re-accumulation after ALD breast reconstruction.

Idiopathic granulomatous mastitis: surgery, treatment, and reconstruction.

Idiopathic granulomatous mastitis is a rare inflammatory breast disease that mimics breast diseases such as inflammatory breast carcinoma, infective mastitis, and inflammatory breast disease of known cause. It is a diagnosis made only after excluding other causes, and although the disease is nonmalignant it may be both locally aggressive and recurrent. Definitive treatment may require radical excision and adjunctive treatment with immunosuppressants. Reconstruction following excision of disease has not been previously described. In those patients who undergo reconstruction, both the surgeon and the patient must be aware of complications associated with residual disease, and the potential involvement of donor sites. Treatment should be undertaken as part of a multidisciplinary team including surgeons and physicians with an interest in inflammatory breast disease. We present two patients diagnosed with idiopathic granulomatous mastitis who were referred to our unit for consideration of reconstruction. One patient underwent autologous breast reconstruction and the other contra lateral surgery to achieve symmetry.