Breast Reconstruction after Surgical Treatment of Ductal Carcinoma In Situ.

The role of plastic surgeon in breast reconstruction is mandatory in those cases of ductal carcinoma in situ (DCIS) requiring a wide surgical excision. The reconstructive treatment must be tailored on each patient with the aim to obtain a good cosmetic result in terms of form and symmetry, avoiding surgical complications.

The Technique of Scarless Latissimus Dorsi in Immediate Breast Reconstruction.

Background: In dealing with the inferior pole coverage of an implant or a tissue expander in the partial submuscular technique, various surgical strategies have been introduced over the years. Among them, ADM and synthetic meshes were intensively studied and performed in order to obtain a good aesthetic result with satisfactory lower pole contouring, create a strong support of the implant and offer flexibility in adapting the volume of a tissue expander to the remaining mastectomy flaps (1,2). However, the viability of the skin from the mastectomy flaps is not always optimal. Vascular impairment and subsequent necrosis can occur at various extent in the mastectomy flaps (3). The necrosis of the mastectomy flaps is unpredictable and sometimes occurs with no obvious cause (4). Implant exposure and extrusion, ADM or mesh exposure are serious complications which can lead to the reconstructive failure. Methods: The scarless latissimus dorsi flap technique was introduced and observed in patients eligible for skin sparing and nipple sparing mastectomy with implant-based submuscular breast reconstruction. The keypoints of the surgical steps are described. Results: The main priorities of the outcome of the reconstructive process were stability and good definition of the lower pole of the reconstructed breast. The good vascularized underlying muscular tissue totally covering the implant increases chances in avoiding exposure or extrusion of the implant. In the advent of partial mastectomy flap necrosis, the healing by secondary intention provided good and stable results. Also, this technique decreases the morbidity and risks related with the change of the patient position during the procedure, improves the aesthetic results, by avoiding additional incisions for harvesting the flap. Conclusions: The scarless latissimus dorsi flap in implant based breast reconstruction is a valuable option for stable results and viable alternative to the use of ADM.

Patient-Reported Quality of Life 3 Months after Breast Reconstruction.

Background: Breast cancer is considered to be the second major cause of cancer death in women after lung cancer. Due to a remarkable progress, the treatments against breast cancer became more efficient and less toxic. In addition, the reconstructive procedures after mastectomy have improved significantly the quality of life especially in younger women. The aim of the study was to evaluate the quality of life of patients 3 months after breast reconstruction. Methods: We performed a prospective study on 25 female patients who underwent immediate or delayed reconstruction of the breast after mastectomy. A health-related quality of life questionnaire was distributed and the answers were evaluated. Results: The patients from the rural area reported that their health in general was much worse than one year ago. The patients with ductal carcinoma reported a serious limitation for vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. 15 patients declared that their general health is good, 8 very good and just two women considered it excellent. Conclusions: Breast reconstruction following mastectomy have an effect on the patient's quality of life. Therefore, there is an increased need to recognize and evaluate the quality of life after post reconstruction.

Contralateral Prophylactic Mastectomy in Patients with Breast Cancer.

Introduction: The rate of contralateral prophylactic mastectomy (CPM) increased within the recent years. The main reasons are: genetic testing, availability of breast reconstruction, more often use of preoperative breast MRI, improvement of postoperative aesthetic results and reimbursement of breast reconstruction. The purpose of this study was to analyze the indication of CPM, it's evolution and the surgical techniques used for this type of surgery. Materials and methods: This prospective study enrolled patients with unilateral breast cancer for which conservative treatment was not an option and underwent CPM concomitant with therapeutic mastectomy, using different techniques, followed by immediate breast reconstruction using alloplastic materials. Results: A total of 45 patients with unilateral breast cancer underwent therapeutic mastectomy and CPM followed by immediate breast reconstruction, between January 2015-December 2020. The mean age was 43.5 years, 64,44% patients had stage I and II breast cancer and 22,22% were triplenegative. The indications for CPM were: pathogenic mutation of BRCA or of other genes associated with high risk of breast cancer, strong family history, suspicious findings on breast MRI, extended micro-calcifications, dense breasts, and extreme anxiety. Conclusions: A growing rate of bilateral mastectomy for unilateral breast cancer was observed. Availability of immediate breast reconstruction and reimbursement plays an important role for patients in choosing CPM. Factors associated with CPM include: young age, pathogenic BRCA mutation, significant family history and triple-negative disease. The rate of immediate postoperative complications was low. CPM is a valid option to reduce the risk of contralateral breast cancer and to achieve a good aesthetic outcome for patients with unilateral breast cancer with high risk of contralateral breast cancer.

Immediate Breast Reconstruction in Large Ptotic Breasts Using the Inferior Based Dermal Flap. Indications and Technique.

Introduction: Achieving good aesthetic outcomes during immediate reconstruction in women with large ptotic breast presents a unique challenge for the reconstructive surgeon. We present our paradigm regarding immediate reconstruction in patients with large ptotic breasts, using the inferiorly based dermal flap. Materials and Methods: Ten patients with large ptotic breasts underwent mastectomy and immediate implant reconstruction at the "Prof. Dr. I. Chiricuta" Institute of Oncology. The mastectomy was carried out using a Wise pattern skin resection with preservation of a dermal flap at the lower pole of the breast. The flap was sutured to the pectoralis major muscle and completed the subpectoral pocket created for the implant. Results: The reconstruction was done bilaterally in three cases with a total number of 13 reconstructed breasts. Of these 11 required dermal flaps. All reconstructions were completed successfully and there were no implant losses. Four breasts (36%) developed superficial necrosis of the tip of the mastectomy flaps at the T junction. Conclusion: The dermal flap technique is safe, versatile and reliable. It is used in a wide array of reconstructive scenarios as it provides the surgeon with an excellent alternative to more costly and unreliable methods.

Breast Reconstruction with Non-Abdominal Autologous Tissue.

The progresses in surgical field are amazing regarding the possibilities of soft tissue reconstruction. Techniques of breast reconstruction have been evolved since the last 40 years. There was a trend from pedicled flaps toward microsurgical free flaps. In the English literature have been reported several types of free flaps for BR. Although DIEP is the workhorse for the reconstruction, there are patients that do not have enough abdominal tissue to use. In those cases, other donor area such as buttock, thigh, lumbar area has been reported. The present article describes the choices for BR with non-abdominal autologous tissue.

Tips and Tricks for Successful Breast Reconstruction Following Radiotherapy Using the Implant-Enhanced Latissimus Dorsi Flap.

Introduction: Adjuvant radiotherapy poses the most serious challenges for surgeons who must choose both the time and the optimal reconstructive method for radiotherapy patients. One of the postmastectomy reconstructive techniques, in patients subjected to radiotherapy, is the method that combines the own tissue with the alloplastic material, the latissimus dorsi flap and the breast implant. This method is highly versatile and can be safely applied to radiotherapy patients. Materials and Methods: Between April 2014 and April 2020, we performed 219 breast reconstructions of which 156 cases were reconstructed with latissimus dorsi flap and implant. The main elements studied were: patient selection for the above mentioned technical procedure, indication of operative moment and type of intervention, preoperative measurements and sketching, minimal scar of the donor area, decision to perform simultaneous symmetrization, simultaneous prophylactic mastectomy with immediate reconstruction, cosmetic appearance, stability and evolution of results over time. The follow-up period was 1 year for all patients, while in the case of some patients up to 5 years. Results: This technique could be applied in all cases with radiotherapy, regardless of the size of the contralateral breast, the technique allowing the shaping of breasts of different volumes. The cosmetic appearance has improved over time, the breast having characteristics similar to the healthy one - shape, natural ptosis, consistency, well-defined inframammary groove. Simultaneous symmetrization by breast reduction, mastopexy with or without implant or breast augmentation led to superior results and a high degree of patient satisfaction. The average duration of recovery was 4 weeks, with rapid social and professional reintegration of patients. The small number of complications - 1 total flap necrosis, 3 cases of partial necrosis, 5 seromas, with a small number of reinterventions - 4, make this method one of the safest in the difficult context of the radiotherapy treatment of prepectoral area. Conclusions: Careful planning of breast reconstruction with the help of the latissimus dorsi flap in combination with the breast implant, the meticulous technique determines stable results over time, with superior cosmetic appearance of the breasts reconstructed with the aid of this method, while minimizing the risk of complications. Thus, the quality of life of patients is much improved, and the social and professional reintegration is relatively fast.

Risk Factor Analysis for Flap and Donor Site Related Complications in 1274 DIEP Flaps - Retrospective Single Center Study.

Background: Breast cancer is the most common cancer affecting women worldwide. In Germany, in almost 70% of cases, women require a complete mastectomy and wish for breast reconstruction which is especially difficult when the breast was previously irradiated. The DIEP flap is then the gold standard for autologous breast reconstruction and shows an overall low complication rate. This study aims to underline the safety of the procedure yet point out potential risk factors for flap edge and fat necrosis in a retrospective series of 1274 DIEP flaps in our center. Patients and Methods: 1274 autologous breast reconstructions with the DIEP flap were performed in 1124 patients between July 2004 and December 2014 in our department. Retrospective risk factor analysis included age, BMI, smoking, chemotherapy and/or radiotherapy and comorbidities. Mean follow-up constituted out of 24 months. Results: Out of 1274 free DIEP flap breast reconstructions, 150 were bilateral reconstructions. In 785 cases the primary indication was previous mastectomy, followed by prior implant-based reconstruction in 265 cases. The total flap loss rate was 0.6%. Patients with a higher BMI and smokers had significantly higher complication rates than the rest of the cohort. Elderly patients ( 65 years), patients with diabetes and ones who had undergone chemo-/ radiotherapy did not present with higher complication rates. Conclusions: The DIEP flap surgery is a well-established method for autologous breast reconstruction with a low complication rate. Yet patient characteristics in terms of risk factors need to be taken into account for result prognosis and satisfactory long-term reconstructive results.

TiLoop Bra Assisted Breast Reconstruction - Our Experience.

Additional covering of the lower pole with allomaterial or its synthetic analogues during immediate breast reconstruction is being perfomed at the N.N. Petrov National Medical Research Oncology Center, Ministry of Healthcare of Russian Federation for last 7 years. Initially, epidermal flap was the only option for lower pole coverage, later ADM was used as part of clinical approbation. Average complication rate ranges from 20-35% due to blood circulatory (supply) disorders. Since 2018, a titanized mesh (TiLoop Bra) been used as a additional coverage of the lower pole. Methods: From July 2018 to April 2019, 103 breast reconstructions were performed using TiLoop-BRA mesh. All operations were performed due to malignant tumors of breast, of which in 94 operations were performed for unilateral breast carcinoma, 9 for bilateral breast carcinoma.74 patients received neoadjuvant therapy, 31 received adjuvant therapy, 17 patients required radiation therapy. Results: Overall complications rates significally decreased. Complete loss of breast implant and mesh endoprosthesis 5.88%, Capsular contracture 17.65 %, Only mesh removal due to painful syndrome 5.88%,* Red breast * syndrome (by analogy with ADM) 5.88%.

6 Years of Breast Reconstruction in One Center - An Objective Analysis.

Background: Breast cancer represents the most common type of neoplasm in women around the world. Breast reconstruction following mastectomy has become a demanding procedure in the treatment of patients suffering from breast cancer. Their major role is to improve the quality of life of women, leading to better aesthetic outcomes. Based on each type of reconstruction, the complications following surgery and the duration of hospital stay, the financial implications slightly vary. Methods: Our study included 168 female patients who underwent immediate or delayed breast reconstruction after mastectomy. We assessed the clinical management of each of these cases and we evaluated the average final cost of the treatment after the reconstruction, focusing on the reconstructive method used, the complications that occurred and the number of days of hospitalization. Results: The total cost of care in breast reconstruction surgery depends on the type of reconstructive procedure used, which consequently affects the duration of hospitalization of the patients. The expenses also depend on the materials that are used: the type of implant/expander or the use of ADM. Costs were higher in patients who underwent breast reconstruction using a latissimus dorsi flap associated with an implant, in comparison to reconstruction using a free flap. Conclusions: Breast reconstruction represents a crucial process in the management of women who underwent mastectomies following cancer and presumes variable financial resources, depending on the chosen reconstructive method.

Robotic Prophylactic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: A prospective Study of 138 Procedures.

Bachground: Robotic breast surgery is an emergent procedure with encouraging preliminary results. The aim of this study is to assess the feasibility and the safety of robotic nipple sparing mastectomy (RNSM) with immediate prosthetic breast reconstruction (IPBR). Methods: This is a prospective study including from December 2015 to January 2020 all RNSM surgeries with IPBR, in patients with moderate ptosis and A B or C cup. The primary endpoint was the rate of major necrosis. Secondary endpoints were conversion rate, postoperative complications (infections, hematoma, implant exposure), aesthetic results and quality of life. Results: 79 patients underwent 138 RNSM with IPBR. The average follow-up was 28 months. 2 procedures required conversion. Two cases of major necrosis occurred (1.4%). 9 surgical site infections were observed (6.5%), 4 infections could be treated with implant replacement. Unfortunately, 5 others resulted in implant loss. 4 other implant losses occurred: 2 due to major necrosis, and 2 due to periprosthetic capsula. In total, 9 implants were lost (6.5%). Esthetical results were mostly very satisfying and quality of life was not affected by the mastectomy. Conclusions: RSNM with IPBR was associated with low rates of major necrosis. It is a safe and reproducible procedure that allows breast reconstruction without visible scar.

Persistent Seroma, a Threat to Implant-Based Breast Reconstruction?

Introduction: Seroma is one of the usual postoperative complications after breast and axillary surgery. It is considered as a consequence of prolonged lymphorrhea. Its persistence means a longer healing process, increased risk of infection and in case of implant-based reconstruction, even implant loss which may result in delaying adjuvant oncologic treatment. Nevertheless the patient's comfort is amplified due to frequent follow-up visits to the hospital for percutaneous drainage and sometimes the seroma might affect the aesthetic result. Materials and Methods: Between 1999 and 2017 a total of 137 patients with mastectomy and implant-based breast reconstruction were included in the study. The risk factors for developing seroma were analyzed and an algorithm for postoperative follow-up and ultrasound-guided needle aspiration was implemented. Results: The seroma rate was 9.49% (13/137 patients). It was associated with skin flap ischemia in 37.5% . Risk factors for developing seroma were: the use of synthetic mesh, smoking and overweight. The rate of implant loss attributed to seroma was 2.18% (3/137). In patients having prolonged lymphorheea, beyond ultrasound-guided needle aspiration, Rifampin solution was used to wash the implant pocket. In these cases, the drainage was reduced by 50% after each visit. Conclusion: Overweight patients and smokers have a higher risk of developing seroma after implant- based breast reconstruction. The use of synthetic meshes for breast reconstruction is also a risk factor for seroma. Rifampin solution for washing the implant pocket might be an option for decreasing the lymphorrhea.

The impact of co-surgeons on complication rates and healthcare cost in patients undergoing microsurgical breast reconstruction: analysis of 8680 patients.

PURPOSE: The use of two operating microsurgeons has been shown to improve the efficiency and reduce the operative duration of microsurgical breast reconstruction (MSBR). However, the impact of this practice on healthcare cost has not been previously assessed. The goal of this study is to query a national claims database to assess complication rates and overall cost in patients undergoing MSBR using co-surgeon (CS) vs. single-surgeon (SS) approach. METHODS: The study cohort, extracted from the MarketScan database, included all female patients who underwent MSBR between 2010 and 2017. Our primary outcome measure was the difference in total healthcare cost between the two operative groups while differences in complication rates were secondary outcome measures. RESULTS: We identified a total of 8680 patients, out of whom 7531 (87%) underwent MSBR with a SS and 1149 (13%) had a CS. Over the study period, the annual incidence rate of MSBR cases using CS increased from 7.2% in 2010 to 23.3% in 2017 (p < 0.001). Following propensity score matching, complications, emergency room visits, readmissions, and reoperations were all similar between the CS and SS groups. The median total healthcare cost was higher for the CS group [US $76,227 (IQR $67,879) vs. $61,340 (IQR $54,318); p < 0.0001], CONCLUSIONS: Use of the CS approach in MSBR has become increasingly prevalent over time. Analyses of a national claims database suggested that the use of CS is a safe option for patients undergoing MSBR. Further research is needed to optimize CS utilization from a costs and outcomes perspective.

Immediate Versus Delayed Breast Reconstruction for Postmastectomy Patients. Controversies and Solutions.

When considering breast reconstruction, two main decisions have to be made: optimal timing and appropriate reconstruction technique,that would best suit each patient, while also taking into consideration the complications and risks that these decisions might lead to. By careful patient selection and individualized breast reconstruction approach, the risks and complications of the procedure can be minimized, while attaining successful aesthetic outcomes and high patient satisfaction. Breast reconstruction can be performed in three different settings: immediate reconstruction - at the time of mastectomy; delayed reconstruction " after the completion of the adjuvant treatment and in a delayed-immediate setting that uses both previous methods" includes tissue expansion at the time of mastectomy and definitive reconstruction performed after completion of the adjuvant treatment. The strategies perfected for decades in breast reconstructive surgery have now made breast reconstruction more possible than ever, thus offering patients the chance to recover after a mastectomy procedure with a new reconstructed breast. Although, the choice of breast reconstruction is not adressed by all breast cancer patients, rates are gradually expanding while new and improved techniques are rapidly developing.

Immediate-DElayed AutoLogous (IDEAL) Breast Reconstruction with the DIEP Flap.

Background: The most common cancer worldwide in women is breast cancer. The increasing number of cases each year, requires a novel curative approach that can combine oncological treatments and breast reconstruction yielding a pleasing and aesthetic breast that is a definitive and long lasting solution. Thus, the Immediate-DElayed AutoLogous (IDEAL) breast reconstruction principle was created to hold up to the standards of the needs of contemporary women. METHOD: The IDEAL protocol for breast reconstruction was developed in our department in cooperation with our breast surgery unit and describes a two-stage approach that implicates neoadjuvant radio-/ chemotherapy treatment regimes and tumor staging before the mastectomy in order to avoid post-mastectomy radiation. In a second step the breast is then reconstructed with autologous tissue for optimal and natural results. CONCLUSION: More and more patients decide to undergo breast reconstruction after breast cancer. The IDEAL concept offers a life-long and safe solution with a low rate of late complications.