Immediate Versus Delayed-Immediate Autologous Breast Reconstruction After Nipple-Sparing Mastectomy.

INTRODUCTION: Autologous reconstruction following nipple-sparing mastectomy (NSM) is either performed in a delayed-immediate fashion, with a tissue expander placed initially at the time of mastectomy and autologous reconstruction performed later, or immediately at the time of NSM. It has not been determined which method of reconstruction leads to more favorable patient outcomes and lower complication rates. METHODS: We performed a retrospective chart review of all patients who underwent autologous abdomen-based free flap breast reconstruction after NSM between January 2004 and September 2021. Patients were stratified into 2 groups by timing of reconstruction (immediate and delayed-immediate). All surgical complications were analyzed. RESULTS: One hundred one patients (151 breasts) underwent NSM followed by autologous abdomen-based free flap breast reconstruction during the defined time period. Fifty-nine patients (89 breasts) underwent immediate reconstruction, whereas 42 patients (62 breasts) underwent delayed-immediate reconstruction. Considering only the autologous stage of reconstruction in both groups, the immediate reconstruction group experienced significantly more delayed wound healing, wounds requiring reoperation, mastectomy skin flap necrosis, and nipple-areolar complex necrosis. Analysis of cumulative complications from all reconstructive surgeries revealed that the immediate reconstruction group still experienced significantly greater cumulative rates of mastectomy skin flap necrosis. However, the delayed-immediate reconstruction group experienced significantly greater cumulative rates of readmission, any infection, infection requiring PO antibiotics, and infection requiring IV antibiotics. CONCLUSIONS: Immediate autologous breast reconstruction after NSM alleviates many issues seen with tissue expanders and delayed autologous reconstruction. Although mastectomy skin flap necrosis occurs at a significantly greater rate after immediate autologous reconstruction, it can often be managed conservatively.

Prepectoral Breast Reconstruction Reduces Opioid Consumption and Pain After Mastectomy: A Head-to-Head Comparison With Submuscular Reconstruction.

BACKGROUND: Acute pain after mastectomy is increased with concurrent breast reconstruction. One postulated advantage of prepectoral breast reconstruction is less postoperative pain; however, no comparisons to partial submuscular reconstruction have been made to date. Here, we examined the postoperative pain experienced between patients with prepectoral and subpectoral breast reconstruction after mastectomy. METHODS: We performed a retrospective chart review of all patients undergoing immediate breast reconstruction with tissue expanders from 2012 to 2019 by a single plastic surgeon. Patient demographics, surgical details, and anesthetic techniques were evaluated, and our primary outcome compared postoperative opioid usage between prepectoral and subpectoral reconstructions. Our secondary outcome compared pain scores between techniques. RESULTS: A total of 211 subpectoral and 117 prepectoral reconstruction patients were included for analysis. Patients with subpectoral reconstructions had higher postoperative opioid usage (80.0 vs 45.0 oral morphine equivalents, P < 0.001). Subpectoral patients also recorded higher maximum pain scores compared with prepectoral reconstructions while admitted (7 of 10 vs 5 of 10, P < 0.004). Multivariable linear regression suggests that mastectomy type and subpectoral reconstruction were significant contributors to postoperative opioid use (P < 0.05). CONCLUSIONS: Prepectoral breast reconstruction was associated with less postoperative opioid consumption and lower postoperative pain scores as compared with subpectoral reconstruction, when controlling for other surgical and anesthesia factors. Future randomized controlled trials are warranted to study how postoperative pain and chronic pain are influenced by the location of prosthesis placement in implant-based postmastectomy breast reconstruction.

Preventing Recurrence in Clean and Contaminated Hernias Using Biologic Versus Synthetic Mesh in Ventral Hernia Repair: The PRICE Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to evaluate which mesh type yields lower recurrence and complication rates after ventral hernia repair. SUMMARY BACKGROUND DATA: More than 400,000 ventral hernia repairs are performed annually in the United States. Although the most effective method for repairing ventral hernias involves using mesh, whether to use biologic mesh versus synthetic mesh is controversial. METHODS: Single-blind, randomized, controlled, pragmatic clinical trial conducted from March 2014 through October 2018; 165 patients enrolled with an average follow up of 26 months. Patients were randomized 1:1 to have their ventral hernias repaired using either a biologic (porcine) or synthetic (polypropylene) mesh. The primary study outcome measure was hernia recurrence at 2 years. RESULTS: A total of 165 patients (68 men), mean age 55 years, were included in the study with a mean follow-up of 26 months. An intention-to-treat analysis noted that hernias recurred in 25 patients (39.7%) assigned to biologic mesh and in 14 patients (21.9%) assigned to synthetic mesh (P = 0.035) at 2 years. Subgroup analysis identified an increased rate of hernia recurrence in the biologic versus the synthetic mesh group under contaminated wound conditions (50.0% vs 5.9%; P for interaction = 0.041). Postoperative complication rates were similar for the 2 mesh types. CONCLUSIONS: The risk of hernia recurrence was significantly higher for patients undergoing ventral hernia repair with biologic mesh compared to synthetic mesh, with similar rates of postoperative complications. These data indicate that the use of synthetic mesh over biologic mesh to repair ventral hernias is effective and can be endorsed, including under contaminated wound conditions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02041494.

Utility of Postoperative Prophylactic Antibiotics in Prepectoral Breast Reconstruction: A Single-Surgeon Experience.

BACKGROUND: Immediate tissue expander placement remains a preferred method for breast reconstruction after mastectomy. The use of prophylactic postoperative antibiotic administration is thought to reduce rates of surgical site infection and reconstructive failure, but has not been studied in patients undergoing reconstruction in the prepectoral plane. METHODS: We retrospectively identified all patients undergoing immediate prepectoral tissue expander placement after mastectomy by a single plastic surgeon from 2015 to 2018. We identified 2 cohorts of patients: one group that received prophylactic antibiotics at the time of discharge and one group that did not. We collected treatment and outcomes data to compare rates of postoperative complications between cohorts. RESULTS: We identified 69 patients with 115 breasts who received discharge antibiotics and 63 patients with 106 breasts who did not. The antibiotic cohort had significantly lower rates of tissue expander loss (4.3% vs 17.0%, P = 0.003), unplanned operation (10.4% vs 24.5%, P = 0.007), and infection (7.0% vs 24.5, P < 0.001). CONCLUSIONS: The use of prophylactic postoperative antibiotics in prepectoral breast reconstruction is associated with significantly lower rates of postoperative complications. Further randomized controlled studies are warranted to explore the effect of antibiotic therapy on outcomes and to determine what the optimal duration of antibiotic therapy may be.

Reconstruction of Intrapelvic Defects Using the Free Anterolateral Thigh Flap: Expanding the Traditional Algorithm.

BACKGROUND: Reconstruction of intrapelvic soft tissue defects traditionally relies on regional pedicled myocutaneous flaps. However, there remain situations in which local options are unavailable. We review our experience treating intrapelvic defects with the anterolateral thigh (ALT) microvascular free flap. METHODS: A retrospective, institutional review was conducted from 2014 to 2018 of patients undergoing microvascular ALT flap reconstruction of intrapelvic defects. Four patients were identified in this cohort out of 92 total pelvic reconstruction cases. RESULTS: All patients underwent abdominoperineal resection (APR) for rectal cancer treatment. In the two male patients, pelvic abscesses and bladder leak necessitated soft tissue reconstruction after radiation and APR. In both, regional tissue options were unavailable, and a buried ALT free flap was used for soft tissue reconstruction. Both female patients developed rectovaginal fistulas secondary to their tumor burden, necessitating posterior vaginal wall resections. Prior surgical scars and ostomies made abdominal wall tissue unavailable; thus, free ALTs were used to eliminate intrapelvic dead space and reconstruct the posterior vaginal wall. In all cases, recipient vessels were the deep inferior epigastric artery and vein. Flap survival was 100%. CONCLUSIONS: Pelvic reconstruction has traditionally been addressed with local/regional pedicled flaps. In cases where these are unavailable, the free ALT flap is a versatile option when buried for intrapelvic reconstruction or posterior vaginal wall lining. We also propose updating Cordeiro et al.'s classic vaginal defect reconstruction algorithm to include the free ALT flap for type IB cases in which the rectus abdominis is unavailable.

Breast Reconstruction Does Not Increase the Incidence of Postmastectomy Pain Syndrome: Results of a Meta-Analysis.

BACKGROUND: Postmastectomy pain syndrome (PMPS) is characterized by neuropathic pain from direct nerve injury during oncologic breast surgery causing chronic pain, often leading to chronic opioid dependence and long-term disability. To our knowledge, this study represents the first meta-analysis that defines the incidence of PMPS in patients undergoing mastectomy, with and without breast reconstruction. METHODS: The Cochrane, Embase, MEDLINE, and PubMed databases were queried. A total of 166 citations from 1991 to 2017 were reviewed to identify 22 unique manuscripts. Inclusion criteria required: (i) minimum 3-month follow-up, (ii) pain in breast, (iii) pain after mastectomy, (iv) documentation of any reconstruction, and (v) minimum of level three evidence. Comprehensive Meta- Analysis Software and Microsoft Excel were used for statistical calculations. RESULTS: Sixteen manuscripts described the prevalence of postmastectomy pain and 11 described the prevalence of postreconstruction pain (5 had data for both). Study population size ranged from 32 to 1165 patients. All studies were classified as level 2 or level 3 evidence. The mean prevalence of pain after mastectomy alone using a random-effects model is 35.6% (30.3%-41.3%). Mean prevalence of pain after mastectomy with reconstruction using the random-effects model is 32.8% (24.4% - 42.5%). Analysis of variance analysis showed no significant difference between prevalence of chronic pain after mastectomy alone versus mastectomy and reconstruction (P = 0.88). CONCLUSIONS: Our meta-analysis establishes that postmastectomy reconstruction does not increase the incidence of PMPS. However, because this neuropathic pain often persists after reconstructive surgery, it is incumbent on the plastic surgeon to counsel patients on PMPS. Moving forward, prospective studies on the effects of reconstruction type and adjunct procedures are warranted.

A Critical Analysis of Prosthetic Augmentation of Autologous Microvascular Breast Reconstruction.

INTRODUCTION: The combined approach using both an implant and autologous tissue for breast reconstruction has become more common over the last 10 years. We sought to provide a systematic review and outcomes analysis of this technique. METHODS: We searched PubMed and the Cochrane Library database to identify studies that described implant augmentation of autologous flaps for breast reconstruction. The references of selected articles were also reviewed to identify any additional pertinent articles. RESULTS: We identified 11 articles, which included 230 patients and 378 flaps. Implants used ranged in size from 90 to 510 cc, with an average size of 198 cc. Implants were more frequently placed at the time of autologous reconstruction and in the subpectoral plane. There were no total flap losses, and partial flap loss occurred in 3 patients (1%). There were no cases of venous or arterial thrombosis and no early return to the operating room for flap compromise. Eight implants (2%) were lost because of infection or extrusion, and capsular contracture occurred in 9 breasts (3%). When stratified by the timing of implant placement (immediate vs delayed), there were no significant differences in any postoperative outcomes except the immediate group had a higher infection rate. CONCLUSIONS: The criteria for women to be candidates for autologous tissue breast reconstruction can be expanded by adding an implant underneath the flap. We found the overall flap loss rate is comparable with standard autologous flap reconstruction, and the implant loss rate is lower than that in patients who undergo prosthetic reconstruction alone.

How to Optimize Prepectoral Breast Reconstruction.

Prepectoral breast reconstruction has become a popular method of postmastectomy breast reconstruction due to its numerous benefits in properly selected patients. Prepectoral reconstruction, as compared with retropectoral position, offers the advantage of leaving the pectoralis muscle undisturbed and in its original anatomic position, resulting in significantly decreased acute and chronic pain, improved upper extremity strength and range of motion, and avoidance of animation deformity. The use of acellular dermal matrices (ADMs) allows for precise control of the breast pocket, resulting in aesthetic outcomes and high patient satisfaction. ADMs have the added benefit of reducing capsular contracture, especially in the setting of postmastectomy radiation therapy. Although prepectoral breast reconstruction is effective, the breast implant is placed closer to the skin flap with less vascularized soft tissue coverage. Therefore, optimizing outcomes in prepectoral breast reconstruction requires careful patient selection, intraoperative mastectomy flap evaluation, and perioperative surgical algorithms specific to prepectoral reconstruction.

The "Dual-Plane" DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are routinely elevated on a single dominant perforator from the deep epigastric vascular system. However, the single perforator may not always perfuse an entire flap adequately, particularly suprascarpal tissue. We often perform "dual-plane" single perforator DIEP flaps by rerouting the superficial (SIEA/V) system directly into a branch of the deep (DIEA/V) vascular system pedicle, thus allowing both systems to contribute and enhance flap perfusion. METHODS: A prospectively collected database of patients undergoing microvascular breast reconstruction was reviewed for patients undergoing "dual-plane" DIEP flaps. These were matched to a similar cohort of patients undergoing "traditional" single perforator DIEP free flaps over the same time period. Treatment demographics and flap-specific morbidity outcomes were assessed, including performance in the setting of radiation. RESULTS: Over 2 years, 23 "dual-plane" DIEP flaps were performed (15 patients), compared with 35 single-perforator "traditional" DIEP flaps (23 patients). Rates of delayed healing were similar between both cohorts (2.9 vs. 4.3%, p = 0.28). Rates of palpable fat necrosis were significantly lower in "dual-plane" DIEP flaps compared with "traditional" flaps (0 vs. 14.3%, p = 0.03). Rates of clinically palpable fat necrosis following radiation were significantly lower in the "dual-plane" flaps (4.3 vs. 40%, p = 0.02). CONCLUSION: The "dual-plane" DIEP flap is one we routinely consider in our algorithm, as it allows for full preservation of functional abdominal musculature, and offers enhanced flap perfusion by incorporating both the deep and superficial (dominant) vascular systems. This results in lower fat necrosis rates, particularly in the setting of post-reconstruction radiation.

Breast Conservation and Negative Margins in Invasive Lobular Carcinoma: The Impact of Oncoplastic Surgery and Shave Margins in 358 Patients.

BACKGROUND: Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, making complete surgical excision difficult. This results in high rates of positive margins and low rates of successful breast-conserving surgery. We hypothesized that utilizing oncoplastic surgical techniques and selective shave margins would be associated with lower positive margin rates and increased breast conservation in women with ILC. METHODS: We performed a retrospective cross-sectional analysis in a large cohort of prospectively collected ILC cases who received surgical treatment at the University of California, San Francisco, between 1992 and 2017. We identified all patients with histologically proven, unilateral or bilateral, stage 1-3 ILC. The primary outcome was positive margin rates, defined as no ink on tumor. RESULTS: We identified 365 tumors in 358 women, with an average age of 61 years, who underwent breast-conserving surgery, and found that the use of oncoplastic techniques (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.21-0.79, p = 0.008) and the selective use of shave margins (OR 0.393, 95% CI 0.22-0.7, p = 0.002) were significantly associated with lower positive margin rates, when adjusted for tumor size and multifocality. The success rate for breast-conservation surgery was 75%, with a 25% conversion rate to mastectomy. CONCLUSIONS: Surgeons should consider routine use of oncoplastic techniques and shave margins when performing breast-conservation surgery for women with ILC as these methods are associated with significantly lower odds of having positive margins and higher breast-conservation rates.

The Evolution of Iliac Bone Graft Donor Site Analgesia in Cleft Patients: Transversus Abdominis Plane Block Is Safe and Efficacious.

BACKGROUND: The transversus abdominis plane (TAP) block has been increasingly used as a means of abdominal wall analgesia. This study aims to determine if TAP block analgesia provides a benefit in cleft patients undergoing alveolar bone grafting with iliac crest cancellous bone graft. METHODS: Two groups of 20 consecutive patients undergoing alveolar bone grafting with iliac crest cancellous bone with either TAP block or indwelling catheter pain pump were examined in a retrospective fashion. Demographic data, pharmacologic use, and hospital length of stay were examined. RESULTS: Mean lengths of stay were identical between both groups. Patients in both groups received similar cumulative doses of morphine equivalents, codeine, ibuprofen, and ondansetron at 6 and 24 hours postoperatively. Transversus abdominis plane block patients received greater amounts of Tylenol at both 6 and 24 hours (P = 0.0015 and P = 0.0106). Pain scores did not differ significantly across our groups at 6 or 24 hours postoperatively. No adverse events were reported with the TAP block procedure. CONCLUSIONS: Patients undergoing TAP blocks receive the benefit of a single stage procedure without an indwelling catheter and similar 6- and 24-hour morphine usage. Given the safety profile of the procedure, its effectiveness and comfort without indwelling catheter, we advocate for TAP block analgesia as an adjunct therapy in the management of postoperative pain in this population.

Complications After Total Skin-Sparing Mastectomy and Expander-Implant Reconstruction: Effects of Radiation Therapy on the Stages of Reconstruction.

BACKGROUND: Many patients undergoing total-skin sparing mastectomy (TSSM) and 2-staged expander-implant (TE-I) reconstruction require postmastectomy radiation therapy (PMRT). Additionally, many patients undergoing TSSM for recurrent cancer have a history of lumpectomy and radiation therapy (XRT). Few studies have looked at the impact of XRT on the stages of TE-I reconstruction. METHODS: Patients undergoing TSSM and immediate TE-I reconstruction between 2006 and 2013 were identified from a prospectively maintained database. Rates of TE-I loss and severe infection requiring intravenous antibiotics were compared in patients with prior XRT (85 cases) and PMRT (133 cases). Complications were divided by stage of reconstruction: first stage (TSSM and TE placement) and second stage (TE-I exchange). RESULTS: Mean follow-up time was 2.5 years. Patients with prior XRT had more complications after the first stage of reconstruction than the second (TE-I loss: 15% vs 5%, P = 0.03; infection: 20% vs 8%, P = 0.04). Patients receiving PMRT had low complication rates after the first stage, when they had not yet received radiation (TE-I loss: 2%; infection: 5%). However, complication rates after TE-I exchange (TE-I loss, 18%; infection, 31%) were significantly higher, and nearly 4-fold higher than patients with prior XRT. CONCLUSIONS: Patients with prior XRT are at high risk for complications after the first stage of TE-I reconstruction after TSSM; however, the risk of complications at the second stage is comparable to patients without radiation exposure and significantly lower than patients receiving PMRT. Patients receiving radiation therapy should be given appropriate preoperative counseling regarding their risks.

Immediate Reconstruction for Plantar Melanoma: A Paradigm Shift.

INTRODUCTION: Plantar melanoma tumors are traditionally treated with wide local excision based on depth of invasion, followed by delayed reconstruction once negative surgical margins are confirmed. However, delayed reconstruction requires care for an open wound, a prolonged treatment course, and the need for an additional surgery. Immediate reconstruction has been shown to be oncologically safe in head and neck melanoma, but little is described in the literature regarding immediate reconstruction in plantar melanoma. We present our experience with immediate reconstruction after wide local excision for lower extremity plantar melanomas. METHODS: We performed a retrospective review of all patients with biopsy-proven plantar melanoma who underwent wide local excision followed by immediate reconstruction of any type between 1999 and 2014 at the University of California, San Francisco. Patient demographics, postoperative complications, reoperation rates, and oncologic outcomes were collected. RESULTS: Thirty-eight patients were identified, with a mean follow-up of 34 months. Skin grafts were the most common method of reconstruction, followed by primary closure, local flaps, and free flaps. Only 1 patient had a major complication, which was skin graft loss requiring reoperation. Eight patients had either local or distant recurrence (21%). DISCUSSION: Immediate reconstruction for plantar melanomas can be safely performed with recurrence rates comparable and in line with previously published studies of wide local excision for plantar melanoma. This technique has the potential to achieve oncologically safe outcomes with less overall morbidity.

Expanding the Indications for Total Skin-Sparing Mastectomy: Is It Safe for Patients with Locally Advanced Disease?

BACKGROUND: Indications for total skin-sparing mastectomy (TSSM) continue to expand. Although initially used only for early-stage breast cancer, TSSM currently is offered in many centers to patients with locally advanced disease. However, despite this practice change, limited data on oncologic outcomes in this population have been reported. METHODS: A retrospective review of a prospectively collected database of all patients undergoing TSSM and immediate reconstruction from 2005 to 2013 was performed. The outcomes for patients with stage 2b and stage 3 cancer were included in the analysis. The primary outcomes included the development of locoregional or distant recurrences. RESULTS: Of 753 patients undergoing TSSM, 139 (18 %) presented with locally advanced disease. Of these 139 patients, 25 (18 %) had stage 2b disease, and 114 (82 %) had stage 3 disease. Most of the patients (97 %) received chemotherapy (77 % neoadjuvant, 20 % adjuvant), whereas 3 % received adjuvant hormonal therapy alone. Of the neoadjuvant patients, 13 (12 %) had a pathologic complete response (pCR) to treatment. During a mean follow-up period of 41 months (range 4-111 months), seven patients (5 %) had a local recurrence, 21 patients (15.1 %) had a distant recurrence, and three patients (2.2 %) had simultaneous local and distant recurrences. None of the local recurrences occurred in the preserved nipple-areolar complex skin. CONCLUSIONS: Patients with locally advanced breast cancer are most at risk for distant rather than local recurrence, even after TSSM. When used in conjunction with appropriate multimodal therapy, TSSM is not associated with an increased risk for local recurrence in this population, even in the setting of low pCR rates.

Comparison of Mammographic Findings Following Oncoplastic Mammoplasty and Lumpectomy Without Reconstruction.

BACKGROUND: Reconstruction of lumpectomy defects with reduction mammoplasty techniques can improve aesthetic outcomes and patient satisfaction. However, one concern with the substantial tissue rearrangement required is the possible difficulty with mammographic follow up and/or increased recommendations for future biopsies. METHODS: We performed a retrospective review of 49 patients who underwent oncoplastic reduction mammoplasty between 2001 and 2009 who were age-matched to patients who underwent lumpectomy without reconstruction. Mammography reports at 6 months, 1, 2, and 5 years postoperatively were reviewed for predominant findings, Breast Imaging Reporting and Data System final assessments, and recommendations for biopsy. RESULTS: There was no significant difference in abnormal mammographic findings prompting biopsy between the two cohorts at 6 months, 2 years, and 5 years postoperatively (p > 0.05). Biopsy rates over the 5-year period did not differ significantly between the two cohorts [9 (18 %) lumpectomy cohort, 12 (24 %) oncoplastic cohort, p = 0.46]. Overall cancer-to-biopsy ratio was 33 % in the lumpectomy cohort and 42 % in the oncoplastic cohort (p = 1.00). CONCLUSIONS: Although substantial tissue rearrangement is performed at the time of oncoplastic reduction mammoplasty, our results reveal no increased incidence of postoperative mammographic abnormalities or unnecessary biopsies compared to lumpectomy alone. This demonstrates that fear of increasing mammographic abnormalities and biopsies after reduction mammoplasty is unfounded and should not prevent utilization of this technique if it can optimize cosmetic outcomes and extend the option of breast conservation.

Radiation and breast reconstruction: Algorithmic approach and evidence-based outcomes.

Postmastectomy radiation (PMRT) in the setting of immediate breast reconstruction has been associated with increased complications and poorer aesthetic outcomes for both autologous and implant reconstructions. Many centers have attempted to mitigate the deleterious effects associated with radiation by implementing an algorithmic approach to breast reconstruction. Although the literature regarding the optimal timing of radiotherapy and breast reconstruction remains controversial, reported outcomes following various algorithms have been encouraging and warrant further consideration. J. Surg. Oncol. 2016;113:906-912. © 2016 Wiley Periodicals, Inc.

Axillary Web Syndrome: Current Understanding and New Directions for Treatment.

BACKGROUND: Axillary web syndrome (AWS) is a poorly understood but common cause of significant morbidity after axillary lymph node dissection for breast cancer. It is characterized by painful scar tissue formation and contracture extending from the axilla down the medial arm which limits shoulder and arm mobility. We sought to gain a better understanding of its pathophysiology and available treatments. Additionally, we present our preliminary experience with 2 novel treatment methods: (1) percutaneous needle cord disruption with fat grafting, (2) Xiaflex injection to the cording. METHODS: In order to gain better understanding of current treatment modalities, we performed a literature search to identify articles that described axillary cording after axillary dissection exclusively for breast cancer. We performed operative percutaneous cord disruption and immediate autologous fat grafting in 18 patients. Xiaflex injection was performed in one patient. Details from the 2 new treatment modalities are described. RESULTS: Described treatments in the literature include physical therapy, nonsteroidal anti-inflammatories, moist heat, and 1 case of Ascueven Forte. Typically, symptoms lasted from 1 week to 2 years, and most cases resolved by 3 months postoperatively with return to preoperative functionality. We found our 2 new treatment modalities markedly improved arm and shoulder range of motion, overall daily functioning, and pain. Aesthetic outcomes were also improved with softening of the cords. CONCLUSIONS: Axillary web syndrome remains an incompletely understood postoperative phenomenon, which warrants further research. Those patients who develop severe cording often do not respond to traditional therapy and may require more aggressive treatment. Our 2 novel techniques provide alternative options for treating this condition.

Outcomes Following Oncoplastic Reduction Mammoplasty: A Systematic Review.

BACKGROUND: Reconstruction of partial mastectomy defects with oncoplastic approaches has become increasingly popular as a strategy for improving aesthetic outcomes and extending the option of breast conservation therapy. However, interpretation of reported oncologic outcomes and postoperative complications has been challenging because of limited data and significant variability in surgical technique and degree of tissue rearrangement. METHODS: Studies describing oncoplastic mammoplasty or partial mastectomy reconstruction were identified from the MEDLINE and Cochrane databases. Only studies reporting the use of oncoplastic reduction mammoplasty techniques with significant breast parenchymal rearrangement were included for analysis. Primary outcomes assessed were postoperative complications and oncologic outcomes, including local recurrence rates and need for re-excision or completion mastectomy. RESULTS: Seventeen articles met the inclusion criteria, representing 1324 oncoplastic cases. Reported follow-up ranged from 20 to 73 months. Of the 12 studies with at least 2 years' mean/median follow-up, the pooled local-regional recurrence rate was 3.1%. Fifteen articles reported re-excision and completion mastectomy rates (3.5% and 3.7%, respectively). Twelve articles reported postoperative complications. Overall, 4.6% of patients had wound dehiscence, 4.3% developed fat necrosis, 2.8% developed an infection, 0.9% had either partial or total nipple necrosis, and 0.6% had seromas. CONCLUSIONS: Partial mastectomy reconstruction with oncoplastic reduction techniques is associated with high rates of successful breast conservation and low rates of required re-excisions, likely due to the ability to take wide tumor margins without compromising aesthetic outcome. Future studies should consistently report complications, recurrences, and patient-reported outcomes to improve our ability to evaluate the use of this technique.

Tissue Expander Reconstruction After Total Skin-Sparing Mastectomy: Defining the Effects of Coverage Technique on Nipple/Areola Preservation.

BACKGROUND: Total skin-sparing mastectomy (TSSM) has become increasingly frequent in recent years, as inclusion criteria continue to expand. Options for tissue expander coverage in these patients include complete submuscular tissue expander coverage and acellular dermal matrix (ADM)-assisted coverage. This study compares both techniques with regard to relevant outcomes, during a recent 1-year period at our institution. METHODS: All women undergoing TSSM and immediate expander placement between January 2012 and January 2013 were prospectively tracked. Patient demographics, expander coverage type, adjuvant treatment, length and characteristics of expansion, and incidence of complications were analyzed. RESULTS: In 1 year, 127 patients underwent TSSM on 202 breasts. Overall, 113 expanders underwent submuscular coverage, and 89 underwent ADM-assisted coverage. Mean intraoperative fill volume was 52 mL in the submuscular cohort and 205 mL in the ADM cohort (P = 0.0001). Mean tissue expander size was 404 mL in the submuscular cohort and 454 mL in the ADM cohort (P = 0.0002). χ analysis demonstrated no differences between the cohorts in incidence of complications, including partial/complete nipple necrosis. CONCLUSIONS: The use of ADM for expander coverage after TSSM allowed for greater initial expander fill. With large and ptotic breasts, this allows for reduced incidence of skin folds in the preserved breast skin pocket, and greater control over final nipple position, as the amount of loose, mobile skin is reduced by the greater initial fill. The safety profile of ADM use after TSSM is equivalent to that of submuscular coverage, with no differences in partial or complete nipple necrosis.

Negative Genetic Testing Does Not Deter Contralateral Prophylactic Mastectomy in Younger Patients with Greater Family Histories of Breast Cancer.

BACKGROUND: Increasing rates of contralateral prophylactic mastectomy (CPM) correlate with adoption of total skin-sparing mastectomy (TSSM). We aimed to characterize patients with unilateral breast cancer who underwent TSSM with CPM or without CPM (No CPM). METHODS: We reviewed all patients with unilateral breast cancer who underwent TSSM from 2006 to 2013. Trends in CPM and genetic testing were evaluated across time. Patient characteristics and complications were compared between CPM and No CPM groups. RESULTS: We identified 591 patients (293 No CPM and 298 CPM) with median follow-up of 25 (interquartile range [IQR] 13-52) months. All patients with deleterious mutations and 58% of those who tested negative for mutations underwent CPM. In patients who tested negative for mutations, CPM was correlated with younger patient age, greater family history, and younger age of relatives diagnosed with breast/ovarian cancer. CPM was associated with an increased risk of superficial nipple necrosis (relative risk [RR] 2.1, 95% confidence interval [CI] 1.12-4.0), wound breakdown (RR 1.62, 95% CI 1.04-2.5), and infections requiring oral antibiotics (RR 1.59, 95% CI 1.16-2.2). In patients with tissue expander/implant reconstruction, CPM was associated with an increased risk of implant exposure (RR 1.95, 95% CI 1.03-3.7) but did not affect the risk of implant loss (RR 0.91, 95% CI 0.56-1.48). CONCLUSIONS: Patients who choose CPM fit the profile of patients with higher risk of contralateral breast cancer (CBC), which may be due to polygenic risk factors that are currently under investigation. Physicians should address patients' fears of CBC, screening concerns, and the risk of complications when considering CPM.