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Leach GA, Clark RC, Tong S, Dean RA, Segal RM, Blair SL, Reid CM. The Intercostal Artery Perforator Flap: Expanding Breast-Conserving Therapy With a Modified Oncoplastic Approach. Ann Plast Surg 2023; 90:S236-S241. [PMID: 36752509 DOI: 10.1097/sap.0000000000003405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Historically, breast-conserving surgery may not be pursued when the oncologic deformity is too significant and/or not tolerant of radiotherapy. Reconstruction using recruitment of upper abdominal wall tissue based on the intercostal artery perforating vessels can expand breast conservation therapy indications for cases that would otherwise require mastectomy. This report aims to describe the expanded use of the intercostal artery perforator (ICAP) as well as detail its ease of adoption. METHODS All patients who underwent ICAP flaps for reconstruction of partial mastectomy defects at a single institution were included. Demographic data, intraoperative data, and postoperative outcomes were recorded. Intercostal artery perforator flap outcomes are compared with standard alloplastic reconstruction after mastectomy. RESULTS Twenty-seven patients received ICAP flaps compared with 27 unilateral tissue expanders (TE). Six cases included nipple-areolar reconstruction, and 6 included skin resurfacing. The average defect size was 217.7 (30.3-557.9) cm 3 . Plastic-specific operative time was significantly longer in the ICAP cohort ( P < 0.01) with no difference in total operative time ( P > 0.05). Length of stay was significantly longer, and major postoperative complications were significantly more common in TE patients ( P < 0.01, P > 0.05). Seven TE patients required outpatient opiate refills (26%) versus 1 ICAP patient (4%) ( P = 0.02). One ICAP patient required additional surgery. Patients reported satisfaction with aesthetic outcomes. Average follow-up in the ICAP cohort was 7 months. CONCLUSIONS Lumpectomy reconstruction using ICAP flaps can effectively expand breast conservation therapy indications in resection of breast skin, nipple-areola, or large volume defects. This technique is adoptable and of limited complexity. Enhancing breast-conserving surgery may improve outcomes compared with mastectomy reconstruction. Intercostal artery perforator patients may require fewer opioids, shorter hospital stays, and lower operative burden.
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Affiliation(s)
- Garrison A Leach
- From the Division of Plastic Surgery, Department of General Surgery
| | - Robert C Clark
- From the Division of Plastic Surgery, Department of General Surgery
| | - Solomon Tong
- From the Division of Plastic Surgery, Department of General Surgery
| | - Riley A Dean
- From the Division of Plastic Surgery, Department of General Surgery
| | | | - Sarah L Blair
- Division of Breast Surgery, Department of General Surgery, University of California San Diego, San Diego, CA
| | - Chris M Reid
- From the Division of Plastic Surgery, Department of General Surgery
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Jonczyk MM, Homsy C, Naber S, Chatterjee A. Examining a decade of racial disparity in partial mastectomy and oncoplastic surgery. J Surg Oncol 2023; 127:541-549. [PMID: 36507913 DOI: 10.1002/jso.27173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/25/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time. METHODS This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis. RESULTS In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%). CONCLUSION BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities.
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Affiliation(s)
- Michael M Jonczyk
- Department of General Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.,Department of Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Christopher Homsy
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Stephen Naber
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Karadeniz Cakmak G. Innovative Standards in Oncoplastic Breast Conserving Surgery: From Radical Mastectomy to Extreme Oncoplasty. Breast Care (Basel) 2022; 16:559-573. [PMID: 35087359 DOI: 10.1159/000518992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/11/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Oncoplastic breast conserving surgery (OBCS), which is the current procedure of choice for eligible BC patients, describes a philosophy that prioritizes oncologic and cosmetic outcomes. However, knowledge gaps regarding training, acceptance, and practice preclude standardization and make it difficult to design algorithmic guidelines to optimize individualized management in the era of precision medicine. SUMMARY The harmony between patient expectations and oncologic goals creates the state of the art of OBCS. Nevertheless, to achieve these goals, multidisciplinary approach is a must. Surgical decisions require a comprehensive evaluation including patient factors, tumor biology, genetics, technical considerations, and adjunct therapies. Moreover, the quality-of-life (QOL) issues should be considered as the highest level of priority with a shared decision making instituted on realistic discussions with the patient. KEY MESSAGES The standardization in OBCS should be initiated via defining a breast surgeon who should gain theorical and practical competence on techniques via national or international educational programs. The algorithmic patient assessment with appropriate documentation before and after surgery should be established. A simple and safe global lexicon should be designed regarding techniques to be proposed and quality metrics to be considered. Additionally, international multicenter prospective trials should be instituted to overcome knowledge gaps. It is evident that OBCS is the perfect union of science with art. Nevertheless, at the very end, the question is not the nature of the surgeon/artist who would be the extremist, the innovator, or the conservative, but the patient's satisfaction, prognosis, and QOL that conclude the cascade of state of the art of OBCS.
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Li X, Cho B, Martin R, Seu M, Zhang C, Zhou Z, Choi JS, Jiang X, Chen L, Walia G, Yan J, Callanan M, Liu H, Colbert K, Morrissette-McAlmon J, Grayson W, Reddy S, Sacks JM, Mao HQ. Nanofiber-hydrogel composite-mediated angiogenesis for soft tissue reconstruction. Sci Transl Med 2020; 11:11/490/eaau6210. [PMID: 31043572 DOI: 10.1126/scitranslmed.aau6210] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 03/15/2019] [Indexed: 12/22/2022]
Abstract
Soft tissue losses from tumor removal, trauma, aging, and congenital malformation affect millions of people each year. Existing options for soft tissue restoration have several drawbacks: Surgical options such as the use of autologous tissue flaps lead to donor site defects, prosthetic implants are prone to foreign body response leading to fibrosis, and fat grafting and dermal fillers are limited to small-volume defects and only provide transient volume restoration. In addition, large-volume fat grafting and other tissue-engineering attempts are hampered by poor vascular ingrowth. Currently, there are no off-the-shelf materials that can fill the volume lost in soft tissue defects while promoting early angiogenesis. Here, we report a nanofiber-hydrogel composite that addresses these issues. By incorporating interfacial bonding between electrospun poly(ε-caprolactone) fibers and a hyaluronic acid hydrogel network, we generated a composite that mimics the microarchitecture and mechanical properties of soft tissue extracellular matrix. Upon subcutaneous injection in a rat model, this composite permitted infiltration of host macrophages and conditioned them into the pro-regenerative phenotype. By secreting pro-angiogenic cytokines and growth factors, these polarized macrophages enabled gradual remodeling and replacement of the composite with vascularized soft tissue. Such host cell infiltration and angiogenesis were also observed in a rabbit model for repairing a soft tissue defect filled with the composite. This injectable nanofiber-hydrogel composite augments native tissue regenerative responses, thus enabling durable soft tissue restoration outcomes.
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Affiliation(s)
- Xiaowei Li
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Brian Cho
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Russell Martin
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Michelle Seu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Chi Zhang
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Zhengbing Zhou
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Ji Suk Choi
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Xuesong Jiang
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Long Chen
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Gurjot Walia
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Jerry Yan
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Megan Callanan
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Huanhuan Liu
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Colbert
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Justin Morrissette-McAlmon
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Warren Grayson
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
| | - Hai-Quan Mao
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA. .,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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