Single Versus Dual Surgeon Approaches to Oncoplastic Surgery: A Comparison of Outcomes.

INTRODUCTION: Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches. METHODS: A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival. RESULTS: A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival. CONCLUSIONS: Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

The impact of body mass index on oncoplastic breast surgery: A multicenter analysis.

BACKGROUND: Obesity has nearly tripled in the last 50 years. During the last decades, oncoplastic breast surgery has become an important choice in the surgical treatment of breast cancer. An association exists between higher body mass index (BMI) and wound complications for major operations, but there is scarce literature on oncoplastic surgery. Hence, our aim was to compare the complication rates among patients who underwent oncoplastic surgery, stratified by BMI. METHODS: Patient data were analyzed from the National Surgical Quality Improvement Program database (NSQIP) for oncoplastic breast procedures (2005-2020). Patients were stratified according to World Health Organization obesity classifications. Multivariate logistic regression was performed to assess risk factors for complications (overall, operative, and wound-related). RESULTS: From a total of 6887 patients who underwent oncoplastic surgery, 4229 patients were nonobese, 1380 had Class 1 obesity (BMI: 30 to <35 kg/m2 ), 737 Class 2 obesity (BMI: 35 to <40 kg/m2 ), and 541 Class 3 obesity (BMI: ≥ 40 kg/m2 ). Greater operative time was found according to higher BMI (p < 0.001). Multivariate analysis adjusted for baseline characteristics showed that patients with obesity Class 2 (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.03-2.23, p = 0.037) and 3 (OR = 1.87, 95% CI 1.24-2.83, p = 0.003) had increased risk of overall and wound complications compared with Nonobese patients. Comparing obese with nonobese patients, there were no differences in rates of deep SSI, organ/space SSI, pneumonia, reintubation, pulmonary embolism, deep vein thrombosis, urinary tract infection, stroke, bleeding, postoperative sepsis, length of stay, and readmission. CONCLUSIONS: Oncoplastic surgery is a safe procedure for most patients. However, caution should be exercised when performing oncoplastic surgery for patients with Class 2 or 3 obesity (BMI ≥ 35 kg/m2 ), given there was a higher rate of overall and wound-specific complications, compared with patients who were not obese or had Class 1 obesity.

The adoption of oncoplastic surgery: Is there a learning curve?

INTRODUCTION: Oncoplastic surgery (OPS) is a form of breast conservation surgery involving partial mastectomy followed by volume displacement or replacement surgery. As the field of OPS is growing, we sought to determine if there was a learning curve to this surgery. METHODS: A retrospective chart review was conducted of all patients who underwent OPS over a 6-year period with a single surgeon formally trained in both Plastic Surgery and Breast Oncology. Cumulative summation analysis (CUSUM) was performed on mean operative time to generate the learning curve and learning curve phases. Outcomes were compared between phases to determine significance. RESULTS: Mean operative time decreased significantly across the 6-year period, generating three distinct learning curve phases: Learner phase (cases 1-23), Competence phase (24-73), and Mastery phase (74 and greater). The overall positive margin rate was 10.9% and there was no significant difference in rates between phases (p = 0.49). Overall complication rates, reoperation rates, and locoregional recurrence remained the same across all phases (p = 0.16; p = 0.65; p = 0.41). The rate of partial nipple loss decreased between phases (p = 0.02). CONCLUSION: As with many complex operations, there does appear to be a learning curve with OPS, as the operative time and the rates of partial nipple loss decreased over time.

The Impact of Premastectomy Versus Postmastectomy Radiation Therapy on Outcomes in Prepectoral Implant-Based Breast Reconstruction.

PURPOSE: Prepectoral implant-based breast reconstruction is being increasingly performed over subpectoral reconstruction because of the reduced invasiveness of the procedure, postoperative pain, and risk of animation deformity. Radiation therapy is a well-known risk factor for complications in implant-based breast reconstruction. The effect of premastectomy versus postmastectomy radiation therapy on outcomes after prepectoral breast reconstruction has not been well-defined. The purpose of this study was to compare the impact of premastectomy versus postmastectomy radiation therapy on outcomes after prepectoral breast reconstruction. METHODS: A retrospective chart review was performed on all patients who underwent prepectoral implant-based breast reconstruction with inferior dermal flap and acellular dermal matrix performed by a single surgeon from 2010 to 2019. Demographic, clinical and operative data were reviewed and recorded. Outcomes were assessed by comparing rates of capsular contracture, infection, seroma, hematoma, dehiscence, mastectomy skin flap necrosis, rippling, implant loss, local recurrence and metastatic disease, between patients receiving premastectomy and postmastectomy radiation therapy and nonradiated patients. RESULTS: Three hundred and sixty-nine patients (592 breasts) underwent prepectoral implant-based breast reconstruction. Twenty-six patients (28 breasts) received premastectomy radiation, 45 patients (71 breasts) received postmastectomy radiation, and 305 patients (493 breasts) did not receive radiation therapy. Patients with premastectomy radiation had higher rates of seroma (14.3% vs 0.2%), minor infection (10.7% vs 1.2%), implant loss (21.4% vs 3.4%) and local recurrence (7.1% vs 1.0%), compared with nonradiated patients (P < 0.05). Patients with postmastectomy radiation had higher rates of major infection (8.4% vs 2.4%), capsular contracture (19.7% vs 3.2%), implant loss (9.9% vs 3.4%), and local recurrence (5.6% vs 1.0%) when compared with nonradiated patients (P < 0.03). Outcomes after prepectoral breast reconstruction were comparable between premastectomy and postmastectomy radiation patients, respectively, with regard to major infection (7.1% vs 8.4%), dehiscence (3.6% vs 1.4%), major mastectomy skin flap necrosis (7.1% vs 2.8%), capsular contracture (10.7% vs 19.7%), implant loss (21.4% vs 9.9%), and local recurrence (7.1% vs 5.6%) (P ≥ 0.184). However, premastectomy radiation patients had a higher rate of seroma compared with postmastectomy radiation patients (14.3% vs 0%; P = 0.005). CONCLUSIONS: In prepectoral implant breast reconstruction, premastectomy and postmastectomy radiation therapy were associated with higher rates of infection and implant loss compared with nonradiated patients. Postmastectomy radiation was associated with a higher rate of capsular contracture compared with nonradiated patients, and a comparable rate of capsular contracture compared with premastectomy radiation therapy patients. Premastectomy radiation was associated with a higher rate of seroma compared with postmastectomy radiation and nonradiated patients.

Management of recurrent bilateral multifocal pseudoangiomatous stromal hyperplasia (PASH).

Pseudoangiomatous stromal hyperplasia (PASH) is a benign hyperplastic condition of the breast that can lead to macromastia. The standard treatment for PASH is focal excision or rarely reduction mammoplasty. We present a rare case of postpartum bilateral rapid breast enlargement and axillary growth that was refractory to reduction mammoplasty. Ultimately, the patient required bilateral mastectomy and two-stage implant-based breast reconstruction. This more extensive form along with its management represents one of the few reported cases in the literature. The decision to pursue bilateral mastectomy was undertaken after exhausting more conservative options. Excellent aesthetic outcome and pain relief was obtained following definitive extirpative and reconstructive surgery.

Impact of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction.

BACKGROUND: This study aimed to compare the impact of postmastectomy radiation therapy (PMRT) on outcomes after prepectoral versus subpectoral implant-based breast reconstruction with local deepithelialized dermal flap and acellular dermal matrix (ADM). METHODS: From 2010 to 2017, 274 patients (426 breasts) underwent prepectoral reconstruction. In this group, 241 patients (370 breasts) were not exposed to PMRT, whereas 45 patients (56 breasts) were exposed to PMRT. Of 100 patients (163 breasts) who underwent partial subpectoral reconstruction, 87 (140 breasts) were not exposed to PMRT, whereas 21 patients (23 breasts) were exposed. The outcomes were assessed by comparing complication rates between the pre- and subpectoral groups. RESULTS: A higher rate of capsular contracture was found for the prepectoral patients with PMRT than for those without PMRT (16.1 vs 3.5%; p = 0.0008) and for the subpectoral patients with PMRT than for those without PMRT (52.2 vs 2.9%; p = 0.0001). The contracture rate was three times higher for the subpectoral patients with PMRT than for the prepectoral patients with PMRT (52.2 vs 16.1%; p = 0.0018). In addition, 10 (83.3%) of 12 cases with capsular contracture in the subpectoral cohort that received PMRT were Baker grades 3 or 4 compared with only 2 (22.2%) of 9 cases of the prepectoral group with PMRT (p = 0.0092). CONCLUSIONS: The patients undergoing subpectoral breast reconstruction who received PMRT had a capsular contracture rate three times greater with more severe contractures (Baker grade 3 or 4) than the patients receiving PMRT who underwent prepectoral breast reconstruction.

The Use of Hemostatic Agents to Decrease Bleeding Complications in Breast Cancer Surgery.

INTRODUCTION: Following breast cancer surgery, patients often require adjuvant radiation and chemotherapy for locoregional and systemic disease control. These procedures may result in postoperative complications, which may delay adjuvant therapy. To potentially decrease these complications, hemostatic agents may be used. This study evaluated the rate of postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in oncologic breast surgery with and without hemostatic agents. METHODS: After obtaining institutional review board approval, a retrospective chart review was performed. Patients who underwent oncoplastic breast surgery, mastectomy with or without expander/implant-based reconstruction, and subsequent reconstruction with expander to implant exchange were included. Data collected included indication for surgery, type of operation, use of hemostatic agent, specifically fibrin sealant (FS, EVICEL®, Ethicon, USA) or combination powder (CP, HEMOBLAST™ Bellows, biom'up, France), length of follow-up, time to JP drain removal, and post-operative complications (seroma, hematoma, or operating room (OR) takeback). This was a consecutive experience where initially no hemostatic agent was used, followed by use of FS, and then CP. RESULTS: The use of a hemostatic agent resulted in fewer bleeding complications and significantly decreased time until JP drain removal. Although not significant, subgroup analysis demonstrated that this was more pronounced in the CP group. JP drain duration was decreased among all procedures for CP compared to FS. CONCLUSIONS: The use of hemostatic agents in oncologic breast surgery may result in decreased postoperative complications and significantly reduce time to JP drain removal.

Closed Incision Negative Pressure Therapy in Oncoplastic Breast Surgery: A Comparison of Outcomes.

We aim to discern the impact of closed incision negative pressure therapy (ciNPT) on wound healing in the oncoplastic breast surgery population. Methods: A retrospective analysis was conducted on patients who underwent oncoplastic breast surgery with and without ciNPT in a single health system over 6 years. Oncoplastic breast surgery was defined as breast conservation surgery involving partial mastectomy with immediate volume displacement or replacement techniques. Primary outcomes were rates of clinically significant complications requiring either medical or operative intervention, including seroma, hematoma, fat necrosis, wound dehiscence, and infection. Secondary outcomes were rates of minor complications. Results: ciNPT was used in 75 patients; standard postsurgical dressing was used in 142 patients. Mean age (P = 0.73) and Charlson Comorbidity Index (P = 0.11) were similar between the groups. The ciNPT cohort had higher baseline BMIs (28.23 ± 4.94 versus 30.55 ± 6.53; P = 0.004), ASA levels (2.35 ± 0.59 versus 2.62 ± 0.52; P = 0.002), and preoperative macromastia symptoms (18.3% versus 45.9%; P ≤ 0.001). The ciNPT cohort had statistically significant lower rates of clinically relevant complications (16.9% versus 5.3%; P = 0.016), the number of complications (14.1% versus 5.3% with one complication, 2.8% versus 0% with >2; P = 0.044), and wound dehiscence (5.6% versus 0%; P = 0.036). Conclusions: The use of ciNPT reduces the overall rate of clinically relevant postoperative complications, including wound dehiscence. The ciNPT cohort had higher rates of macromastia symptoms, BMI, and ASA, all of which put them at increased risk for complications. Therefore, ciNPT should be considered in the oncoplastic population, especially in those patients with increased risk for postoperative complications.

The Use of Hemostatic Agents to Decrease Bleeding Complications in General Plastic Surgery Procedures.

Within plastic surgery, hematomas and seromas are frequently reported complications that can negatively impact wound healing and result in significant morbidity in patients. As a result, there has been considerable interest in hemostatic agents to complement traditional methods of hemostasis. The purpose of this study was to evaluate postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in general plastic surgery procedures with and without hemostatic agents. METHODS: After obtaining institutional review board approval, a retrospective chart review was performed. Patients who underwent bilateral breast reduction, panniculectomy, or abdominoplasty were included. Data collected included indication for surgery, type of operation, use of hemostatic agent, specifically fibrin sealant (FS, EVICEL, Ethicon, USA) or combination powder (CP, HEMOBLAST Bellows, Biom'up, France), length of follow-up, time to JP drain removal, postoperative complications, and specimen weight. This was a consecutive experience where initially no hemostatic agent was used, followed by use of FS, and then CP. RESULTS: The use of a hemostatic agent resulted in reduced time duration for JP drain use and overall fewer recorded complications in the hemostatic agent groups. Although not significant, the hemostatic agent group (FS and CP) experienced fewer hematomas and seromas compared with the nonhemostatic agent group. JP drain duration was significantly less among breast reduction (3.46 versus 6.92 days, P < 0.01) for CP when compared with FS. CONCLUSION: The use of hemostatic agents in general plastic surgery procedures may result in decreased postoperative complications and significantly reduce time to JP drain removal.

Risk of lymphoma associated with combination anti-tumor necrosis factor and immunomodulator therapy for the treatment of Crohn's disease: a meta-analysis.

BACKGROUND & AIMS: Although anti-tumor necrosis factor (TNF) therapy can effectively treat Crohn's disease (CD), there is concern that it might increase the risk of non-Hodgkin's lymphoma (NHL). A meta-analysis was performed to determine the rate of NHL in adult CD patients who have received anti-TNF therapy and to compare this rate with that of a population-based registry and a population of CD patients treated with immunomodulators. METHODS: MEDLINE, EMBASE, Cochrane Collaboration, and Web of Science were searched. Inclusion criteria included randomized controlled trials, cohort studies, or case series reporting on anti-TNF therapy in adult CD patients. Standardized incidence ratios (SIR) were calculated by comparing the pooled rate of NHL with the expected rate of NHL derived from the Surveillance Epidemiology & End Results (SEER) database and a meta-analysis of CD patients treated with immunomodulators. RESULTS: Twenty-six studies involving 8905 patients and 21,178 patient-years of follow-up were included. Among anti-TNF treated subjects, 13 cases of NHL were reported (6.1 per 10,000 patient-years). The majority of these patients had previous immunomodulator exposure. Compared with the expected rate of NHL in the SEER database (1.9 per 10,000 patient-years), anti-TNF treated subjects had a significantly elevated risk (SIR, 3.23; 95% confidence interval, 1.5-6.9). When compared with the NHL rate in CD patients treated with immunomodulators alone (4 per 10,000 patient-years), the SIR was 1.7 (95% confidence interval, 0.5-7.1). CONCLUSIONS: The use of anti-TNF agents with immunomodulators is associated with an increased risk of NHL in adult CD patients, but the absolute rate of these events remains low and should be weighed against the substantial benefits associated with treatment.

A Predictive Model for Determining Permanent Implant Size During 2-Stage Implant Breast Reconstruction.

BACKGROUND: Two-stage tissue expander (TE)/permanent implant (PI) breast reconstruction remains the most commonly performed technique in breast reconstruction. Predictions for the PI size preoperatively impact on the number and range of implants made available at TE exchange. This study aims to identify critical preoperative variables and create a predictive model for PI size. METHODS: Patients who underwent 2-stage implant breast reconstruction from 2011 to 2017 were included in the study. Linear and multivariate regression analyses were used to identify significant preoperative variables for PI volume. RESULTS: During the study period, 826 patients underwent 2-stage TE/PI breast reconstruction. Complete records were available for 226 breasts. Initial TE fill ranged from 0% to 102% with a mean final fill of 100.6% of TE volume. The majority of PIs were smooth round (98.2%), silicone (90%) implants. In a multivariate analysis, significant variables for predicting PI size were TE final fill volume (P < 0.0001), TE size (P = 0.03), and a history of preoperative radiation (P = 0.001). Relationships between these 3 variables were utilized to form a predictive model with a regression coefficient of R2 = 0.914. CONCLUSIONS: Significant variables for predicting PI volume were TE final fill volume, TE size, and a history of preoperative radiation. The ability to more accurately predict the PI volume can improve surgical planning, reduce consignment inventory, and simplify operating room workflow.

Superficial granulomatous pyoderma of the face: a case report and review of the literature.

INTRODUCTION: Superficial granulomatous pyoderma (SGP) is a rare variant of pyoderma gangrenosum (PG) and differs from classic PG in its indolent clinical course, lack of associated underlying disease, the finding of a granulomatous infiltrate on histology, and better prognosis with less-aggressive therapies. METHODS: We report on a case of SGP involving the face following local reexcision of a biopsy scar. RESULTS: The patient developed an indolent ulceration following an excision of an unfavorable scar on her face. DISCUSSION: Superficial granulomatous pyoderma is usually responsive to conservative treatment with antibacterial or local anti-inflammatory agents. Facial involvement with SGP is particularly rare and tends to be more refractory to conservative management. Superficial granulomatous pyoderma involving the face appears to respond better to intensive treatment with systemic corticosteroids or immunosuppressants. To prevent poor cosmetic and functional outcomes in patients with nonhealing lesions, it is important for surgeons to recognize the clinical and histopathologic presentation of SGP and consider initiating a more aggressive management approach for SGP involving the face.