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Wu ZY, Han HH, Kim HJ, Lee JW, Chung IY, Kim J, Lee SB, Son BH, Eom JS, Jung JH, Kim SB, Gong G, Kim HH, Ahn SH, Ko B. A propensity score-matched comparison of recurrence outcomes after immediate implant vs autologous flap reconstruction in patients receiving neoadjuvant chemotherapy for breast cancer. Breast Cancer Res Treat 2021; 187:417-425. [PMID: 33740204 DOI: 10.1007/s10549-021-06114-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/21/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE We compared oncologic outcomes between breast cancer patients who underwent immediate implant-based breast reconstruction (IBBR) and those who underwent autologous flap reconstruction (AFR) after neoadjuvant chemotherapy (NACT). METHODS The study group comprised 536 patients with primary breast cancer who underwent NACT followed by immediate IBBR or AFR. After propensity score matching, 138 patients in the IBBR group and 276 patients in the AFR group were selected for comparisons of locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and breast cancer-specific survival (BCSS). RESULTS No significant differences were observed between the matched groups in locoregional recurrence rates (IBBR vs. AFR: 12.3% vs. 12%; P = 0.915) and distant metastasis (13% vs. 17%; P = 0.293). There was also no significant difference between the groups in LRRFS (P = 0.956), DFS (P = 0.606), DMFS (P = 0.283), or BCSS (P = 0.121). The 5- and 10-year LRRFS rates were 87.6% and 85.9% in the IBBR group, and 87.7% and 86.1% in the AFR group; the 5- and 10-year DFS rates were 79% and 77.5% in the IBBR group, and 77% and 75% in the AFR group; the 5- and 10-year DMFS rates were 85.9% and 85.9% in the IBBR group, and 83.2% and 81.8% in the AFR group; and the 5- and 10-year BCSS rates were 97.8% and 91.3% in the IBBR group, and 91.8% and 86% in the AFR group, respectively. CONCLUSIONS In this propensity score-matched analysis of oncologic outcomes in breast cancer patients who underwent immediate reconstruction after NACT, no significant differences were observed between the IBBR and AFR groups.
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Wu ZY, Han HH, Kim HJ, Lee J, Chung IY, Kim J, Lee S, Eom JS, Kim SB, Gong G, Kim HH, Son BH, Ahn SH, Ko B. Data on distant metastasis and survival after locoregional recurrence following nipple-sparing mastectomy and immediate breast reconstruction. Data Brief 2021; 35:106837. [PMID: 33665246 PMCID: PMC7900209 DOI: 10.1016/j.dib.2021.106837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 10/26/2022] Open
Abstract
Nipple-spring mastectomy (NSM) with immediate breast reconstruction is being increasingly used in the treatment of breast cancer [1]. However, there are limited available data on the prognostic implications of locoregional recurrence (LRR) following this surgical procedure. This article is a supplementary resource of the original research article by Wu ZY et al. entitled "Locoregional Recurrence Following Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: Patterns and Prognostic Significance" [2] and presents data regarding the subsequent distant metastasis following the first LRR, as well as the prognoses for isolated local recurrences according to the site of recurrence after NSM and immediate breast reconstruction for primary breast cancer. Data from a total of 1,696 patients with primary breast cancer who underwent NSM with immediate reconstruction from March 2003 to December 2016 at the Asan Medical Center, Seoul, Korea, were retrospectively reviewed. An LRR as the first event was found to have developed in 172 patients. Among these, 117 cases (6.9%) involved isolated local recurrence, including 52 cases (3.1%) of nipple-areola complex recurrence, 41 cases (2.4%) of skin/subcutaneous recurrence, and 24 cases (1.4%) of chest wall recurrence. Kaplan-Meier survival analysis and the log-rank test were performed to compare the subgroups of local recurrence. In 172 patients with LRR, subsequent distant metastases were observed in 30 cases (17.4%). Our data may be helpful for conducting further in-depth investigations on salvage treatment options in patients with LRR following NSM and immediate breast reconstruction.
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Wu ZY, Han HH, Kim HJ, Lee J, Chung IY, Kim J, Lee S, Han J, Eom JS, Kim SB, Gong G, Kim HH, Son BH, Ahn SH, Ko B. Locoregional recurrence following nipple-sparing mastectomy with immediate breast reconstruction: Patterns and prognostic significance. Eur J Surg Oncol 2021; 47:1309-1315. [PMID: 33495030 DOI: 10.1016/j.ejso.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/21/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION There are limited available data on the prognostic implications of locoregional recurrence (LRR) after nipple-sparing mastectomy (NSM) and immediate reconstruction. In this study, we investigated the patterns and prognosis associated with LRR following this treatment approach for breast cancer. METHODS A total of 1696 patients with primary breast cancer who underwent NSM with immediate reconstruction from March 2003 to December 2016 were retrospectively analyzed. Post-recurrence disease-free survival (DFS) and distant metastasis-free survival (DMFS) rates were calculated using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate analyses using the Cox proportional hazards model were performed to evaluate the prognostic factors associated with the DFS and DMFS. RESULTS After a median follow-up period of 84 months, we identified 172 patients (10.1%) with an LRR as the first event. The 5-year post-recurrence DFS rates for the nipple-areola complex recurrence (NCR), skin or subcutaneous recurrence/chest wall recurrence (SCR/CWR), and regional recurrence (RR) groups were 89.1%, 73%, and 59.4%, respectively (P = 0.009), and the 5-year post-recurrence DMFS rates for the NCR, SCR/CWR, and RR groups were 96%, 82.8%, and 59.7%, respectively (P < 0.001). In multivariate analysis, a time to LRR ≤2 years (P = 0.016) and the site of LRR (P = 0.022) were significantly associated with the post-recurrence DFS. CONCLUSIONS NCR is more likely to be detected as a non-invasive recurrence and is associated with more favorable overall outcomes than other LRR types. The interval to LRR and its site of onset seem to be associated with the prognostic outcomes.
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Wu ZY, Han J, Eom JS, Ahn SH, Ko B. ASO Author Reflections: Do Shorter Tumor-to-Nipple Distances Compromise the Local Oncologic Safety of Nipple-Sparing Mastectomy? Ann Surg Oncol 2021; 28:4292-4293. [PMID: 33417119 DOI: 10.1245/s10434-020-09453-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 12/31/2022]
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Jo T, Hur J, Min K, Kim EK, Han HH, Eom JS. Immediate breast reconstruction after salvage mastectomy: Case control outcome comparisons of DIEP flap and DTI reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1495-1502. [PMID: 33386262 DOI: 10.1016/j.bjps.2020.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cancer recurrence after breast-conserving therapy is most often managed by salvage mastectomy. Successful breast reconstruction immediately after salvage mastectomy, however, remains challenging because the reconstruction is performed on previously irradiated breast tissue. METHODS Records of patients who underwent breast reconstruction from June 2010 to June 2019 were reviewed, including their demographic characteristics, methods of breast reconstruction, and early and late outcomes. Deep inferior epigastric perforator (DIEP) flaps and direct-to-implant (DTI) reconstructions following salvage mastectomies were compared with reconstructions following completion or primary mastectomies. Patients who underwent reconstruction followed by postmastectomy radiotherapy (PMRT) and patients followed up for less than 6 months were excluded. RESULTS DIEP flaps in 27 breasts that underwent salvage mastectomy were compared with DIEP flaps in 32 breasts that underwent completion and 564 that underwent primary mastectomy. Rates of early complications, including microsurgical revision and total flap loss, and of late complications (>6 months after surgery), including fat necrosis and flap volume loss, did not differ significantly. DTI reconstruction in 20 breasts that underwent salvage mastectomy was compared with DTI reconstruction in 12 breasts that underwent completion and 351 that underwent primary mastectomy. Wound healing problems, including wound dehiscence and delayed wound healing (15% vs. 2.6%, P = 0.0022), and capsular contracture (30% vs. 5.4%, P = 0.0000), were significantly more frequent in breasts that underwent salvage than primary mastectomy. CONCLUSIONS DIEP flap is a successful reconstruction option after salvage mastectomy. DTI reconstruction is associated with higher rates of wound healing problems and capsular contracture after salvage than after primary mastectomy.
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Min K, Jeon DN, Choi EJ, Lee TJ, Eom JS, Han HH, Kim EK. Outcomes of saline implant-based immediate breast reconstruction: 15-year follow-up results. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2020. [DOI: 10.14730/aaps.2020.02257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Jo T, Kim EK, Eom JS, Han HH. Comparison of transverse upper gracilis and profunda femoris artery perforator flaps for breast reconstruction: A systematic review. Microsurgery 2020; 40:916-928. [DOI: 10.1002/micr.30670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 10/03/2020] [Accepted: 10/07/2020] [Indexed: 11/06/2022]
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Seok Nam Y, Hong E, Kwon JG, Kim IB, Eom JS, Han HH. Safety of Retrograde Flow of Internal Mammary Vein: Cadaveric Study and Anatomical Evidence. J Reconstr Microsurg 2020; 36:316-324. [PMID: 31994157 DOI: 10.1055/s-0039-1701032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Additional second vessels may be required to handle multiple flaps used to add breast volume, boost blood flow for supercharging, or use salvage recipient vessels. In these situations, retrograde internal mammary vessel flow can be used although this causes doubts and concerns. PATIENTS AND METHODS Forty sides of the chests of 20 fresh cadavers with intact thoracic cages and internal mammary veins (IMV) were used in the study. IMV valve numbers and locations were checked, and the bifurcation was confirmed. A retrograde fluorescent angiography and a saline infusion test were followed to confirm flow direction. RESULTS Twenty-eight vessels were identified in 40 sides of the chest; of them, 45% had no valves. A mean 0.7 valves per chest side were identified; 23 (82.1%) of 28 valves were located above the second intercostal space (ICS). A mean 1.76 communicating veins were found between the IMV bifurcation. In all cadavers, a crossing vein connecting the left and right medial IMV was confirmed just below the xiphoid process. Fluorescent angiography and a saline infusion test proved that the retrograde flow was caudal through the bifurcated IMV to the communicating, intercostal, and crossing veins. CONCLUSION The IMV valve was present in 55% of our subjects and located concentrically above the second ICS level. It is highly unlikely that the retrograde flow was disturbed because the retrograde anastomosis level was below the second ICS. Furthermore, the bifurcation, intercostal, and crossing veins across the xiphoid process enabled valve-less detour flow. Thus, retrograde IMV flow is considered safe.
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Suh YC, Oh TM, Lee YH, Kim EK, Han HH, Eom JS. Effects of hydrochlorothiazide on drainage volume and seroma formation in deep inferior epigastric perforator flap breast reconstruction: Randomized controlled trial. J Plast Reconstr Aesthet Surg 2019; 73:663-672. [PMID: 31843386 DOI: 10.1016/j.bjps.2019.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 10/15/2019] [Accepted: 11/22/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Seroma is a recognized complication encountered at the reconstructed breast and donor site after abdominal-based breast reconstruction. Seroma is caused by lymphatic channel disruption and the formation of a large space between the deep fascia during flap elevation. Surgical techniques to preserve the lymphatics and secure the closure of the donor site can reduce seroma formation. This study investigated the safety and effectiveness of the diuretic hydrochlorothiazide at reducing interstitial fluid accumulation and seroma formation during deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS Sixty patients with breast cancer who underwent skin- or nipple-sparing mastectomy and DIEP flap reconstruction were enrolled between August 2016 and June 2017. The patients were randomly assigned to receive either 25 mg per day of hydrochlorothiazide from the second to the twentieth day after surgery (treatment) or no diuretic (control). The clinicopathological characteristics, drainage time, and drainage volume were statistically compared between the two groups. RESULTS The average total drainage volume at the donor site was 291 mL in the treatment group and 434 mL in the control group (p = 0.003). The differences in body mass index and flap weight between the two groups were not statistically significant (p = 0.879 and p = 0.963, respectively). No hypotension or electrolyte imbalance was noted during the follow-up. CONCLUSIONS Intake of 25 mg per day of hydrochlorothiazide tablets effectively reduced the total abdominal drainage volume and removal time of indwelling drains. However, the adverse effects should be further investigated in a large population and multiracial cohort before using hydrochlorothiazide for seroma prevention.
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Min K, Choi EJ, Lee YH, Eom JS, Son BH, Ahn SH, Kim EK. Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer. Ann Surg Treat Res 2019; 97:168-175. [PMID: 31620390 PMCID: PMC6779953 DOI: 10.4174/astr.2019.97.4.168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/11/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Skin grafts have been widely used in managing extensive chest wall defects after mastectomy for advanced breast cancer. However, their durability and tolerability to radiotherapy is still controversial. A thoracoabdominal (TA) flap with a few technical refinements can safely transfer a larger flap while minimizing complications. Methods From January 2007 to February 2018, a retrospective review was performed to compare 2 groups after wide breast excision: skin graft group (group 1) and lateral-based, single vertical incision rotation-advancement TA flap (group 2). Patients' demographics, operative details, complications, hospital stay, postoperative outpatient visits, cost, and start of adjuvant therapy were analyzed between the 2 groups. Results During the study period, 34 patients received skin graft and 41 patients received TA flap. group 2 had a shorter hospital stay (6.41 ± 2.64 days vs. 12.62 ± 4.60 days, P < 0.001) and shorter time to complete wound healing (29.27 ± 18.68 days vs. 39.24 ± 27.70 days, P = 0.03) than group 1. There was also a difference in the period from surgery to initiation of adjuvant therapy (group 1, 45.04 days ± 17.79 days; group 2, 37.07 ± 15.38 days, P = 0.073). Although limitation in shoulder motion was more frequent in group 2, limitation of motion for >1 year was observed in 4 patients in only group 1 (43.90% vs. 38.24%, P = 0.613). Conclusion TA flap has a simple design that minimizes concerns involving the donor site. Moreover, it does not require complicated procedures and allows for re-elevation whenever necessary. Finally, it guarantees faster wound recovery than skin graft with fewer complications.
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Choi JW, Kim YC, Jeon DN, Jeong WS, Koh KS, Oh TS, Eom JS, Kim EK, Hong JP, Suh HP. Impact of Recipient Vein Selection on Venous Patency and Free Flap Survival in 652 Head and Neck Reconstructions. J Reconstr Microsurg 2019; 36:73-81. [DOI: 10.1055/s-0039-1695054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background This study was conducted to evaluate the impact of choosing a particular recipient venous system on venous patency and flap survival in 652 head and neck free flap reconstructions.
Methods A retrospective review was performed. Patient factors investigated included: age, sex, type of flap, tumor location, history of radiation, presence of previous neck dissection, tumor stage, and any underlying disease. Data related with recipient vein including the number of anastomosis, the repair technique, the type of recipient vein, and the configuration of selected venous system were examined. The impact of patient factors and parameters related with recipient vein on the venous patency and flap survival were analyzed using bivariate and multivariate analyses.
Results Of 652 free flaps, 36 flaps (5.5%) were re-explored due to venous congestion and 28 flaps (77.8%) were salvaged. The overall survival rate of total free flaps was 98.8%. The type of recipient venous system was found to be an insignificant factor with respect to venous congestion and flap survival in multivariate analysis. A history of radiation treatments was the only factor associated with a higher risk of venous compromise (odds ratio [OR] = 13.138, p < 0.001) and a lower rate of flap survival (OR = 20.182, p = 0.002).
Conclusion The selection of recipient venous systems has no impact on venous patency and flap survival. History of radiation treatment was the only factor associated with venous congestion and flap failure. Since no single method can ensure a successful reconstructive result, selecting the optimal recipient vein should be based on individual patient factors and the surgeon's experience.
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Lee TJ, Cho JM, Jo T, Han WY, Maldonado AA, Eom JS, Kim EK. Volumetric changes of the pedicled transverse rectus abdominis musculocutaneous flap and the contralateral native breast during long-term follow-up. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2019. [DOI: 10.14730/aaps.2019.01690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cha HG, Kang MK, Han HH, Kim EK, Eom JS. Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction. J Reconstr Microsurg 2019; 35:622-630. [PMID: 31141822 DOI: 10.1055/s-0039-1692168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. METHODS We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. RESULTS The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was -0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. CONCLUSION The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.
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Cha HG, Kwon JG, Han HH, Eom JS, Kim EK. Appropriate Prophylactic Antibiotic Use in Clean Wound Surgery Under Local Anesthesia. J Korean Med Sci 2019; 34:e135. [PMID: 31050225 PMCID: PMC6497983 DOI: 10.3346/jkms.2019.34.e135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/22/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Although guidelines to prevent surgical site infections (SSIs) were published more than a decade ago, prophylactic antibiotics are still used subjectively in clinical practice. In this study, we evaluated the safety of single-dose preoperative intravenous antibiotics without postoperative antibiotics in the field of clean wound surgery performed under local anesthesia. We also surveyed the present clinical conditions for prophylactic antibiotic use in the plastic surgery departments of training hospitals in Korea. METHODS A total of 360 consecutive patients who underwent clean wound surgery under local anesthesia in an outpatient clinic from March 2018 to October 2018 were reviewed. In the study group, a single surgeon administered first-generation cephalosporins intravenously within 1 hour of skin incision and did not prescribe additional antibiotics. In the control group, 2 other surgeons prescribed oral first-generation cephalosporins postoperatively for 2 to 3 days without preoperative antibiotics. A telephone survey about perioperative antibiotic regimens was conducted at the departments of plastic surgery in training hospitals. RESULTS There were 128 patients in the study group and 232 patients in the control group. There were no significant differences between the 2 groups regarding SSIs and other surgical complications. A total of 41 training hospitals answered the survey and every hospital had protocols of prescribing postoperative oral antibiotics routinely at the time of discharge with a mean duration of 3.9 days. Only 11 hospitals (26.8%) prescribed parenteral antibiotics before surgery as well as postoperative oral antibiotics. CONCLUSION Intravenous injection of single-dose first-generation cephalosporins 1 hour before surgery without postoperative antibiotics did not increase the incidence of SSIs compared with the usual practice of giving only postoperative antibiotics prescription for 2 to 3 days in cases of clean wound surgery performed under local anesthesia. Proper antibiotic prophylaxis should be performed by surgeons in training hospitals without hesitation.
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Han HH, Kang MK, Song SY, Lee HC, Kim EK, Eom JS. Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest. J Plast Reconstr Aesthet Surg 2018; 71:1310-1316. [PMID: 30017669 DOI: 10.1016/j.bjps.2018.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/04/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022]
Abstract
Deep inferior epigastric perforator (DIEP) flap is associated with less donor site morbidity than transverse rectus abdominis myocutaneous flap. However, abdominal muscle atrophy and donor site complications caused by denervation during pedicle dissection cannot be avoided. This retrospective study investigated the change in the rectus abdominis muscle volume after DIEP flap harvest. Of 395 patients who underwent unilateral DIEP flap breast reconstruction between August 2007 and July 2017, 25 patients with >2-year postoperative abdominal computed tomography data were evaluated. Preoperative and postoperative images of the abdominal muscle after pedicle dissection and the nonoperated side were compared. The volume of the muscles from the lower margin to the umbilicus was determined by using OsiriX image analysis application. The muscle volumes on the side of pedicle dissection decreased from 72.63 ± 23.29 cm3 preoperation to 53.09 ± 16.93 cm3 postoperation (p < 0.001). The corresponding volumes on the side without dissection were 73.29 ± 19.25 cm3 and 60.89 ± 18.79 cm3 (p < 0.001). The percentage of postoperative retained volume relative to the preoperative retained volume was 75.65% ± 19.18% on the pedicle dissection side and 84.65% ± 19.00% on the contralateral side. The 9% difference was not statistically significant (p = 0.10). No major abdominal complications were observed. Despite nerve injury during DIEP flap surgery, the volume loss of the involved and contralateral muscles did not differ. More than 75% of the abdominal muscle volume was retained. Muscle integrity was well maintained without any postoperative complications.
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Lee SB, Lee JW, Son BH, Eom JS, Kim EK, Lee TJ, Ahn SH. Oncologic safety of skin-sparing mastectomy followed by immediate reconstruction in young patients with breast cancer. Asian J Surg 2018; 42:274-282. [PMID: 29908898 DOI: 10.1016/j.asjsur.2018.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/05/2018] [Accepted: 04/13/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUNDS This study aimed to compare the oncologic outcomes of nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM) followed by immediate reconstruction with those of conventional mastectomy (CM) in young patients aged under 35 years old with breast cancer. METHODS We analyzed retrospectively 2889 patients who underwent mastectomy for breast cancer at Asan Medical Center from January 2003 to December 2008. We compared NSM/SSM followed by immediate reconstruction with CM in patients under 35 years old by analyzing clinicopathologic features, breast cancer specific survival rate (BCSS), distant metastasis free survival rate (DMFS), and local recurrence rate (LRR). RESULTS Out of a total of 2889 patients, we performed NSM/SSM in 118 patients and CM in 141 patients aged less than 35 years old. DMFS were 85.3% and 73.4% in NSM/SSM and CM, respectively (p = 0.001). BCSS were 90.7% and 73.0% in NSM/SSM and CM, respectively (p = 0.001). After adjusting for stage, there were no statistically significant differences between the two groups with respect to DMFS and BCSS. The type of surgery was not a prognostic factor in multivariate analysis for DMFS and BCSS (CM vs. NSM/SSM: DMFS HR = 0.67, p = 0.215; BCSS: HR = 0.66, p = 0.265). CONCLUSIONS Compared to CM, NSM/SSM followed by immediate breast reconstruction is oncologically safe and could be a viable surgical treatment in young patients under 35 years old with breast cancer.
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Lee SB, Lee JW, Kim HJ, Ko BS, Son BH, Eom JS, Lee TJ, Ahn SH. Long-term outcomes of patients with breast cancer after nipple-sparing mastectomy/skin-sparing mastectomy followed by immediate transverse rectus abdominis musculocutaneous flap reconstruction: Comparison with conventional mastectomy in a single center study. Medicine (Baltimore) 2018; 97:e0680. [PMID: 29718895 PMCID: PMC6393080 DOI: 10.1097/md.0000000000010680] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To evaluate the oncological outcomes of patients with breast cancer after nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM), followed by immediate reconstruction, as compared to conventional mastectomy (CM).SSM/NSM has been increasingly used to treat women with breast cancer who wish to preserve the overlying breast skin, but concern exist regarding its oncological safety due to the potential for residual breast tissue. We report our experience performing SSM/NSM for breast cancer treatment compared to CM with a long follow-up period.All consecutive patients who underwent mastectomy for breast cancer at Asan Medical Center between January 1993 and December 2008 were identified by retrospective medical chart review. The patients who underwent NSM/SSM, followed by immediate breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap (TRAM), were compared to the patients who underwent CM in terms of breast-cancer specific survival (BCSS) rate, distant metastasis-free survival (DMFS) rate, and local recurrence (LR) rate.During the study period, 6028 patients underwent mastectomy for breast cancer. Of these, 1032 and 4996 underwent NSM/SSM with TRAM and CM, respectively. Their median follow-up durations were 94.4 (range, 8.1-220.2) and 110.8 (range, 6.1-262.0) months, respectively. Their 5 year BCSS rates were 95.4% and 88.1%, respectively (log-rank, P < .001). Their 5 year DMFS rates were 93.0% and 85.6%, respectively (log-rank, P < .001).Relative to CM, NSM/SSM, followed by immediate breast reconstruction, may be a viable and oncologically safe surgical treatment in selected patients with breast cancer.
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Han HH, Kwon JG, Kim EK, Eom JS. Breast reconstruction in a patient with a ventriculoperitoneal shunt using a DIEP flap. Microsurgery 2017; 38:345-346. [PMID: 29283183 DOI: 10.1002/micr.30289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/07/2017] [Accepted: 12/15/2017] [Indexed: 11/10/2022]
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Lee HC, Eom JS, Kim EK, Lee TJ. Does the Sequence of Tattooing and Nipple Reconstruction Affect Nipple Projection? Ann Plast Surg 2017; 79:430-432. [DOI: 10.1097/sap.0000000000001122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yim JH, Lee YH, Kim YC, Kim EK, Lee TJ, Yun J, Eom JS. Time and Speed of Vascular Pedicle Dissection in Deep Inferior Epigastric Artery Perforator Flap Elevation. J Reconstr Microsurg 2017; 33:557-562. [PMID: 28561135 DOI: 10.1055/s-0037-1603351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Breast reconstruction using deep inferior epigastric artery perforator (DIEP) free flap is widely used because of the advantages of minimizing donor-site morbidity, but it requires technical competency in vascular dissection. This study evaluated the influence of patient factors and vascular status on the time and speed of dissection of the vascular pedicle.
Methods DIEP free flap procedures were performed in 49 patients assigned to immediate or delayed reconstruction groups. Factors that significantly influenced the time required and the speed of dissection were evaluated.
Results The average total dissection time was 55.9 minutes (34.5 minutes for the intramuscular dissection and 21.4 minutes for the submuscular dissection). The dissection speed for the total vascular pedicle was 2.65 cm/10 minutes (1.71 cm/10 minutes for the intramuscular dissection and 4.30 cm/10 minutes for the submuscular dissection). The presence of a Pfannenstiel scar, length of the vascular pedicle in the intramuscular area, and the number of microclips used significantly correlated with the total dissection time.
Conclusion The length of the intramuscular pedicle, number of microclips used, and presence of a Pfannenstiel scar significantly correlated with the total dissection time of the vascular pedicle. An assessment prior to the surgery can reduce the time of operation and make it easier to elevate the flap.
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Jeong WS, Han W, Eom JS. Comparison of Aesthetic Outcomes Between Vertical and Horizontal Flap Insets in Breast Reconstruction with the TRAM or DIEP Flaps. Aesthetic Plast Surg 2017; 41:19-25. [PMID: 28032178 DOI: 10.1007/s00266-016-0757-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/30/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tissue transfer, such as use of the transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) free flaps, is considered a standard method. However, outcomes may vary among inset methods. Here we compared the aesthetic outcomes of breast reconstructions using vertical and horizontal flap inset methods. METHODS We, respectively, reviewed 274 patients who underwent unilateral post-mastectomy breast reconstruction using TRAM or DIEP free flaps between April 2006 and December 2013. Photographs (frontal and bilateral oblique views) obtained 6 months post-operatively were evaluated. Symmetry scores and regional volume discrepancy scores were compared between the vertical and horizontal inset groups. Symmetry scores were adjusted for 11 potential confounding factors on multivariate regression analysis. RESULTS The vertical inset method was associated with higher total symmetry scores, projection, and ptotic naturalness scores. On multivariate regression analysis, the inset method was an independent predictor of outcomes. Regional volume discrepancy score analysis showed a greater tendency for more symmetrical volumes in the upper, medial, and lateral poles with the vertical inset. CONCLUSION The flap inset method is one of the key determinants of aesthetic breast reconstruction outcomes. The vertical inset method was associated with superior aesthetic outcomes and enabled balanced distribution of flap volume to the four poles of the breast. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Kim YC, Yun JY, Lee HC, Yim JH, Eom JS. Nipple reconstruction with combination of modified CV flap and contralateral nipple composite graft. J Plast Reconstr Aesthet Surg 2017; 70:243-247. [PMID: 28065406 DOI: 10.1016/j.bjps.2016.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/23/2016] [Accepted: 11/27/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Numerous nipple reconstruction methods have been proposed including the use of local flaps and composite grafts, but most methods have shown a significant loss of projection. We combined a modified CV flap with a composite graft (nipple sharing) to maximize the projection and volume of the new nipple and reduce the size of the contralateral nipple. METHODS In total, 30 patients underwent nipple reconstruction using a combined method between January 2013 and November 2015. This technique was selected if the diameter of the contralateral nipple was large and the thickness of the skin was less than 2 mm. After the modified CV flap was created, a composite graft from the contralateral nipple was placed between the V flaps and the C flap. The loss of projection and the ratio of the new nipple to the contralateral nipple were evaluated 12 months after surgery. RESULTS Nipple reconstruction was successful in all cases. The projection at 12 months after reconstruction was 68% of the initial projection, and the mean projection ratio of the new nipple to the contralateral nipple was 0.81. There was no complication in the donor nipple; in fact, the shape was improved with nipple reduction, and the scar was inconspicuous. CONCLUSIONS Nipple reconstruction that combines a modified CV flap and composite graft can maximize the nipple projection and provide a chance for nipple symmetry as the two components will act synergistically.
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Lee TJ, Oh TS, Kim EK, Suh H, Ahn SH, Son BH, Lee JW, Cho J, Eom JS. Risk factors of mastectomy skin flap necrosis in immediate breast reconstruction using low abdominal flaps. J Plast Surg Hand Surg 2016; 50:302-6. [PMID: 27121604 DOI: 10.3109/2000656x.2016.1170026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The purpose of this study was to determine the risk factors associated with mastectomy skin flap necrosis during immediate reconstruction with TRAM or DIEP flaps. METHODS This study reviewed 1116 cases of immediate breast reconstruction over 10 years. Patients ranged in age from 29-76 years (average = 45.1 years), and had an average follow-up period of 65.6 months. Thirteen factors (age, BMI (body mass index), smoking habits, diabetes ptosis grade, midclavicle-to-nipple distance, neoadjuvant chemotherapy, free or pedicled flap, mastectomy method, surgeon, stage, axillary dissection, mastectomy weight) known to be associated with mastectomy flap necrosis were retrospectively analysed. The odds ratios of the risk factors were calculated using logistic regression analyses. RESULTS Mastectomy skin flap necrosis occurred in 247 cases (22.1%). Univariate regression analysis showed that the odds ratio of age, BMI, ptosis grade, midclavicle-to-nipple distance, free flap, mastectomy method, surgeon, stage, and mastectomy weight were significant and the odds ratios determined using multivariate analysis were significant for mastectomy method, surgeon, and mastectomy weight. CONCLUSION During breast reconstruction using abdominal tissue, the independent risk factors that affect mastectomy skin flap necrosis include the mastectomy method, surgeon, and the weight of the mastectomy specimen. Awareness of the impact of each risk factor will lead to the modification and individualisation of surgical techniques and continually improve outcomes.
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Jeong WS, Yun J, Lee TJ, Eom JS, Kim EK. Histologic comparison between the internal mammary artery and the deep inferior epigastric artery and clinical implications for microsurgical breast reconstruction. J Plast Surg Hand Surg 2015; 49:234-7. [PMID: 25761820 DOI: 10.3109/2000656x.2015.1021815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The internal mammary artery (IMA) is one of the most popular recipients for microsurgical breast reconstruction. However, it is often separated into sleeve-like layers when it is handled. This study tried to explain this unique behaviour of the IMA through histologic observation. METHODS Nine pairs of IMAs and DIEAs were harvested and subject for haematoxylin-eosin and Verhoeff's elastic staining. Thickness of the tunica media and the number of elastic lamellae were compared. Samples of the IMA, the DIEA, and the thoracodorsal artery from another patient were observed through the transmission electron microscope to further show the structural differences. RESULTS The most notable difference was presence of multiple elastic lamellae in tunica media in the IMAs, which was barely present in the DIEAs. The mean number of elastic lamellae was 9.2 in the IMA group and 1.0 in the DIEA group (p < 10(-9)). A transmission electron microscope showed that the tunica media of the DIEA and the TDA was densely packed with smooth muscle cells, while the muscle cells distributed sparsely in the IMA. CONCLUSIONS The IMA is an elastic artery which is characterised by multiple layers of elastic lamellae while relatively lacking in smooth muscle cells. The wall of the IMA is easily dissected between the tunica media and the adventitia, or at the outer 1/3 of the tunica media. The inner structure is easily torn if microsutures do not engage the tunica adventitia.
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Park JS, Eom JS, Choi SH, Kim YH, Kim EK. Use of a serratus anterior musculocutaneous flap for surgical obliteration of a bronchopleural fistula. Interact Cardiovasc Thorac Surg 2015; 20:569-74. [PMID: 25636324 DOI: 10.1093/icvts/ivv005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/27/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Successful management of post-resection bronchopleural fistula (BPF) is a challenge, and various loco-regional flaps have been used to directly cover or to enhance closure of the bronchial stump. The serratus anterior muscle (SAM) is one of the workhorse flaps, although its use as a musculocutaneous flap has been debated. Here, we present our early experience with serratus anterior musculocutaneous (SAMC) flaps for the obliteration of BPF. METHODS A retrospective review of patients with surgical management of BPF from April 2005 to June 2014 was performed. A de-epithelized SAMC flap has replaced the conventional SAM flap since August 2013. Nine of consecutive former SAM flaps and 5 consecutive later SAMC flaps were identified. A detailed review of the SAMC flap cases was performed to describe medical and surgical history, BPF diagnosis and location, and the outcome of the flap surgery. RESULTS All five BPFs treated by SAMC flap were greater than 1 cm in diameter and all occurred on the right side. The leading primary diagnosis of a BPF was lung cancer, and the 4 lung cancer patients all underwent previous irradiation. The average size of the skin paddle was 19 × 6.6 cm(2), and the average volume of the skin paddle was 100.3 cm(3). Recurrence of the BPF was noted in 1 patient 6 weeks after surgery. In 4 of 5 patients, viable adipose tissue was confirmed by computed tomography scans. CONCLUSIONS The SAMC flap holds merits of a local flap such as short operation time, relative safety, no need of position change and faster recovery, with increased freedom of flap transfer and additional volume, thus widening surgical indication of the large, recalcitrant BPFs. We suggest that the SAMC flap could be safely harvested and used for management of a BPF or similar intrathoracic lesion when extensive flap length or bulk is required.
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