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Frasson AL, Falcone AB, Barbosa F, Anton de Souza AB, Malhone C, Miranda I, Vollbrecht B, Rodriguez Martinez Frasson MA, Kobe L, Lichtenfels M. Low rate of complications in nipple-sparing mastectomy for patients with BRCA1 and BRCA2 mutation. Per Med 2023; 20:493-501. [PMID: 37909344 DOI: 10.2217/pme-2023-0084] [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] [Indexed: 11/03/2023]
Abstract
Background: To describe the indications and outcomes of BRCA mutation carriers undergoing nipple-sparing mastectomy (NSM). Methods: In this retrospective study, 76 BRCA mutation carriers with no cancer who opted to undergo risk reduction NSM or diagnosed with breast cancer (BC) who opted to undergo therapeutic NSM were included. Results: Indications for NSM: cancer treatment (n = 33), bilateral risk reduction (n = 39) and contralateral prophylactic NSM (n = 4). In a mean follow-up of 45 months (median: 30 months), one patient (2.5%) undergoing risk-reducing NSM developed a new BC. One (3%) local, one (3%) ipsilateral axillary and one (3%) distant recurrence were observed in BC patients. No partial or total nipple necrosis occurred. Conclusion: NSM is safe for reducing the risk of BC development in BRCA mutation carriers and for treating cancer.
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Affiliation(s)
- Antônio Luiz Frasson
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Ana Beatriz Falcone
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Fernanda Barbosa
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Alessandra Borba Anton de Souza
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Carolina Malhone
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Isabela Miranda
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Betina Vollbrecht
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Monica Adriana Rodriguez Martinez Frasson
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
| | - Luiza Kobe
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
| | - Martina Lichtenfels
- Breast Cancer Group, Albert Einstein Hospital, Albert Einstein Avenue 627, 05652-900, São Paulo, Brazil
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Ipiranga 6690, 90610-000, Porto Alegre, Brazil
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Frasson AL, Falcone AB, Miranda I, Souza ABAD, Vollbrecht B, Barbosa F, Frasson MARM, Lichtenfels M. Nipple-sparing Mastectomy with Immediate Implant-based Reconstruction for Patients with Pure Ductal Carcinoma in Situ. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:376-384. [PMID: 35623619 PMCID: PMC9948099 DOI: 10.1055/s-0042-1742315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The presence of an extensive intraductal component is associated to an increasing risk of relapse in the nipple-areola complex. The aim of the present study was to evaluate the outcomes of patients diagnosed with ductal carcinoma in situ (DCIS) who underwent nipple-sparing mastectomy (NSM) with immediate breast reconstruction using silicone implants. METHODS We retrospectively analyzed the postoperative complications and oncological safety of 67 breast cancer patients diagnosed with pure DCIS who underwent NSM with immediate breast reconstruction using silicone implants between 2004 and 2018. RESULTS Among the 127 NSM procedures performed, 2 hematomas (1.5%) and 1 partial nipple necrosis (0.7%) were observed. After a mean follow-up of 60 months, the local recurrence rate was of 8.9%, the disease-free survival rate was of 90%, and 1 of the patients died. CONCLUSION Despite the local recurrence rate, we showed that NSM with immediate breast reconstruction using silicone implants is a feasible surgical approach, with a low rate of complications and high survival rates for patients with a diagnosis of pure DCIS when breast-conserving surgery is not an option.
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Affiliation(s)
- Antônio Luiz Frasson
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Beatriz Falcone
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Isabela Miranda
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Betina Vollbrecht
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | - Martina Lichtenfels
- Mastology Service, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J, Davison PG. Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options. Semin Plast Surg 2021; 35:181-188. [PMID: 34526866 PMCID: PMC8432995 DOI: 10.1055/s-0041-1731464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.
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Affiliation(s)
- Hillary Nepon
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Edward M. Reece
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Peter G. Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place. Plast Reconstr Surg 2020; 145:317-327. [DOI: 10.1097/prs.0000000000006441] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Paprottka FJ, Schlett CL, Luketina R, Paprottka K, Klimas D, Radtke C, Hebebrand D. Risk Factors for Complications after Skin-Sparing and Nipple-Sparing Mastectomy. Breast Care (Basel) 2019; 14:289-296. [PMID: 31798388 DOI: 10.1159/000503218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/05/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction In order to achieve a complication-free breast reconstruction, it is fundamental for each individual patient case to determine preoperatively certain risk factors that might have a negative impact on the postoperative result after skin-sparing (SSM) or nipple-sparing mastectomy (NSM). Methods A retrospective study of 39 female breast cancer patients who received SSM or NSM breast reconstruction in our department (time interval: 2010-2015), was performed. The study focus is on determining patient characteristics (e.g., demographics, history of radiotherapy/chemotherapy, menopausal status, amount of resected breast tissue) leading to higher complication rates. Results Overall, 50 mastectomies (27 SSM and 23 NSM) with 6 immediate and 35 immediate 2-stage tissue expander breast reconstructions amounting to a total of 41 surgical interventions (n = 41) were carried out. Median follow-up time was 2 years and 5 months (range 121-1,863 days). Increased complication rates were associated with the following patient characteristics: age >50 years (p < 0.05) and personal history of cardiovascular disease (p < 0.05). Increased but not significant risk factors included postmenopausal status (p = 0.07), radiotherapy prior to SSM/NSM (p = 0.06), and weight of resected breast tissue >438 g (p = 0.09). Conclusion This work identified age >50 years and personal history of cardiovascular disease to be risk factors for increased complication rates following SSM and NSM. Therefore, the given findings should be taken into account when selecting patients for these 2 procedures.
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Affiliation(s)
- Felix J Paprottka
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Diakonieklinikum Rotenburg, Rotenburg (Wümme), Germany
| | - Christopher L Schlett
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Rosalia Luketina
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Karolin Paprottka
- Department of Clinical Radiology, Campus Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dalius Klimas
- Department of Orthopaedics and Trauma Surgery, DIAKO Bremen, Bremen, Germany
| | - Christine Radtke
- Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
| | - Detlev Hebebrand
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Diakonieklinikum Rotenburg, Rotenburg (Wümme), Germany
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Weenk M, Wunschel P, Heine E, Strobbe LJ. Factors influencing the decision to pursue immediate breast reconstruction after mastectomy for breast cancer. Gland Surg 2017; 6:43-48. [PMID: 28210551 DOI: 10.21037/gs.2016.11.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Immediate breast reconstruction (IBR) after mastectomy has shown to be oncologically safe and to improve quality of life in breast cancer patients. However, most women undergoing mastectomy do not undergo IBR. In this study, we aim to identify breast surgeon-related factors in considering IBR and factors affecting patients' decision to choose for IBR. METHODS Retrospective analysis of the records of breast cancer patients who underwent mastectomy with or without IBR between 2010 and 2013. We documented all information whether or not a patient underwent IBR after mastectomy. RESULTS Of 437 patients, 97 (22.2%) underwent IBR, 89.8% of which received tissue expanders. Patient who did not undergo IBR had a higher age (62.2 versus 51.9 years, P<0.001) and higher body mass index (BMI) (27.0 versus 24.3, P<0.001). Hundred three patients declined IBR, mainly because considering reconstruction as too much trouble. In 128 cases the breast surgeon did not offer IBR, mostly because of the predicted need for post mastectomy radiation. Approximately 11% of the patients were not informed about IBR. CONCLUSIONS Anticipated radiation therapy, higher age and higher BMI were important breast surgeon-related factors in refraining from IBR. Almost one third of all patients declined IBR. In almost 10% of all patients, IBR was not discussed.
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Affiliation(s)
- Mariska Weenk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philipp Wunschel
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Erwin Heine
- Department of Plastic Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Luc J Strobbe
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
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The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures. Arch Plast Surg 2016; 43:328-38. [PMID: 27462565 PMCID: PMC4959975 DOI: 10.5999/aps.2016.43.4.328] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 05/18/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4–156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.
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Quinn TT, Miller GS, Rostek M, Cabalag MS, Rozen WM, Hunter-Smith DJ. Prosthetic breast reconstruction: indications and update. Gland Surg 2016; 5:174-86. [PMID: 27047785 DOI: 10.3978/j.issn.2227-684x.2015.07.01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres. METHODS A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000. RESULTS After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients. CONCLUSIONS Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.
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Affiliation(s)
- Tam T Quinn
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - George S Miller
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Marie Rostek
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Miguel S Cabalag
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Warren M Rozen
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - David J Hunter-Smith
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
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Otte M, Nestle-Krämling C, Fertsch S, Hagouan M, Munder B, Richrath P, Stambera P, Abu-Ghazaleh A, Andree C. Conservative mastectomies and Immediate-DElayed AutoLogous (IDEAL) breast reconstruction: the DIEP flap. Gland Surg 2016; 5:24-31. [PMID: 26855905 DOI: 10.3978/j.issn.2227-684x.2015.05.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND With the development of conservative mastectomies, there are an increasing number of women seeking immediate implant based and autologous breast reconstruction. Despite the oncologic safety of the procedures, the focus will be on the timing of reconstruction. METHODS Our plastic surgery unit is focused primarily on autologous breast reconstruction and is part of an interdisciplinary breast center. We offer immediate breast reconstruction (IBR) with autologous tissue for patients with positive BRCA 1 and 2, ductal carcinoma in situ (DCIS), invasive cancer without margin problems to the skin, as well as to correct poor oncologic and aesthetic breast conserving therapy (BCT) outcomes. In the majority of cases we prefer an Immediate-DElayed AutoLogous (IDEAL) breast reconstruction concept with a two-stage procedure. RESULTS Over the last 10 years we performed more than 1,600 breast reconstructions with free flaps, performing the deep inferior epigastric perforator (DIEP) flap as our first choice for autologous tissue. We recommend IDEAL breast reconstruction, however approximately 15% of our cases are immediate one stage conservative mastectomies and breast reconstruction with the DIEP flap. CONCLUSIONS For immediate reconstruction, the aesthetic outcome should not take precedence over oncologic considerations. Immediate one-stage, breast reconstruction with autologous tissue can be offered to the suitable patients which is most likely a healthy women with a small-to-medium sized non ptotic breast receiving a conservative mastectomy. In all other cases, we recommend an IDEAL breast reconstruction approach in order to achieve a final result that is both satisfyingly pleasing and oncologically safe.
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Affiliation(s)
- Maximilian Otte
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Carolin Nestle-Krämling
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Sonia Fertsch
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Mazen Hagouan
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Beatrix Munder
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Philip Richrath
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Peter Stambera
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Alina Abu-Ghazaleh
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
| | - Christoph Andree
- 1 Department of Plastic and Aesthetic Surgery, 2 Department of Senology, Sana Kliniken Düsseldorf, Düsseldorf, Germany
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