National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study

Major Clinical Adverse Events of Breast Implant in the Manufacturer and User Facility Device Experience Database

OBJECTIVE

Search the Manufacturer and User Facility Device Experience database to collect information on adverse events of breast implant. We analyzed the local complications and the breast implant illness (BII) of silicone breast implants, as well as saline breast implants separately, aim to provide a reference for women who want to breast augmentation.

MATERIALS AND METHODS

The Manufacturer and User Facility Device Experience database was queried for events reports related to the breast implant between July 1, 2012, and June 30, 2022. Event year and reporting year were summarized. Patient problem was collected and analyzed to distinguish between local complications and BII.

RESULTS

A total of 108,728 adverse events in the past 3 years were analyzed, silicone breast implants accounted for 62.1% and saline breast implants accounted for 37.9%. The most common local complication of women receiving silicone breast implants was "Capsular Contracture," accounting for 48.73%. However, the incidence of "capsular contracture" in women who received saline breast implants was only 17.49%. The most common BII was "fatigue/weakness" in both women receiving 2 different breast implants, 17.20% in women receiving silicone breast implants and 24.71% in women receiving saline breast implants. Of note, in all the reports, there was a wide variation in the timing of reporting as compared with the timing of the adverse event.

CONCLUSIONS

Although the adverse events of breast implant cannot completely be determined from this study, we provide a reference for women who want to get breast implants, so that they can choose breast implants more carefully. In addition, a better understanding of BII may allow them to think further about whether the benefits of breast implants outweigh the risks.

Using a Machine Learning Approach to Predict the Need for Elective Revision and Unplanned Surgery after Implant-based Breast Reconstruction

Two-stage implant-based reconstruction after mastectomy may require secondary revision procedures to treat complications, correct defects, and improve aesthetic outcomes. Patients should be counseled on the possibility of additional procedures during the initial visit, but the likelihood of requiring another procedure is dependent on many patient- and surgeon-specific factors. This study aims to identify patient-specific factors and surgical techniques associated with higher rates of secondary procedures and offer a machine learning model to compute individualized assessments for preoperative counseling. A training set of 209 patients (406 breasts) who underwent two-stage alloplastic reconstruction was created, with 45.57% of breasts (185 of 406) requiring revisional or unplanned surgery. On multivariate analysis, hypertension, no tobacco use, and textured expander use corresponded to lower odds of additional surgery. In contrast, higher initial tissue expander volume, vertical radial incision, and larger nipple-inframammary fold distance conferred higher odds of additional surgery. The neural network model trained on clinically significant variables achieved the highest collective performance metrics, with ROC AUC of 0.74, sensitivity of 84.2, specificity of 63.6, and accuracy of 62.1. The proposed machine learning model trained on a single surgeon's data offers a precise and reliable tool to assess an individual patient's risk of secondary procedures. Machine learning models enable physicians to tailor surgical planning and empower patients to make informed decisions aligned with their lifestyle and preferences. The utilization of this technology is especially applicable to plastic surgery, where outcomes are subject to a variety of patient-specific factors and surgeon practices, including threshold to perform secondary procedures.

A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review

INTRODUCTION

Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study.

METHODS

The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared.

RESULTS

Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05).

CONCLUSION

This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Patient satisfaction of breast reconstructive surgery following mastectomy in Brunei

OBJECTIVE

To evaluate the impact of Breast Reconstructive Surgery (BRS) on patients' satisfaction and quality of life following mastectomy for breast cancer.

METHODS

A multi-method design study comprising quantitative and qualitative research was conducted between October to December 2019. The quantitative component consisted of a cross-sectional study using the Breast-Q questionnaire and the qualitative component involved in-depth interviews with eligible patients (N = 16) who underwent BRS following mastectomy for breast cancer. Quantitative analysis was performed including Fisher's exact test and One-way Analysis of Variance where a p-value of <0.05 was regarded as statistically significant. Qualitative data was thematically analysed using Braun and Clarke's thematic analysis.

RESULTS

14 out of 16 eligible patients participated in the study. We observed the lowest-scale score was for 'satisfaction with nipples' (mean score 32.7), followed by 'physical well-being: abdomen' (mean score 69.5). Despite a median score of 70 for 'satisfaction with breasts', patients were satisfied with the overall outcome of BRS (median score 80.5). Thematic analysis yielded three themes i.e. "I feel beautiful again" that described patients' satisfaction with aesthetic outcome with autologous reconstruction; "Striving for normality" that indicated BRS established back a sense of normality and improve their self-confidence and lastly, "I was well taken care of" highlighted the importance of providing 'well-informed' care to ensure overall satisfaction of their BRS journey.

CONCLUSION

The uptake of BRS remains low since its availability in 2012, despite an overall increase in breast cancer cases in Brunei annually. Patients who underwent BRS have shown an increase BREAST-Q scores in breast satisfaction, psychosocial and sexual well-being after breast cancer treatment. Delivering high-quality patient-centred services and providing adequate information can influence the level of satisfaction for overall outcome. BRS should be considered as an important healthcare priority in Brunei and routinely be offered in the management of breast cancer.

"No-back-scar" Latissimus Dorsi Muscle Flap and Tissue Expander: A Valuable Strategy for Secondary Breast Reconstructions

An overall complication rates for implant-based breast reconstruction (IBBR) have been reported from 29 to 46%, particularly in the setting of adjuvant radiotherapy. Although the majority of the literature describes autologous conversion in such scenario, a microsurgical flap is not always feasible. The aim of the paper is to assess surgical and patient-reported outcomes of breast reconstruction using a Latissimus Dorsi muscle Flap (LDMF), harvested without a back scar, in combination with a tissue expander for a two-staged reconstruction in the setting of a previously failed IBBR. All consecutive patients undergoing a two-stages LDMF IBBR between January 2016 and June 2020 were retrospectively identified. A minimal length vertical incision along the posterior axillary line was used for LD flap harvest. Demographic, clinical and surgical data were collected. Aesthetic outcome was evaluated with the Aesthetic Item Scale, and BREAST-Q was used to assess patients' reported outcomes. Twenty-one patients met the inclusion criteria. Mean age was 45.6 years, and the average follow-up was 41.2 months after tissue expander replacement with definitive implant. All patients completed the secondary reconstructive procedure, without major complications both at reconstructive and donor flap site. All women reported to be very satisfied with the final breast reconstruction. Second-attempt implant-based breast reconstruction for patients with a previously failed IBBR is challenging. A conversion from prosthetic to a mixed breast reconstruction with a "no-back scar" LD flap and tissue expander can be considered as a valuable strategy, especially when an abdominal-based autologous breast reconstruction is not feasible or refused by the patients.Level of Evidence IV 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 .

An Evaluation of Native Breast Dimension and Tissue Expander Inflation Rate on the Risk of Capsular Contracture Development in Postmastectomy Reconstruction

INTRODUCTION

Capsular contracture is a common complication after 2-stage breast reconstruction. The relationships between native breast size, the rate of tissue expander expansion, and capsule formation have not been elucidated. This study aims to evaluate how these factors contribute to capsular contracture and establish cutoff values for increased risk.

METHODS

A data set consisting of 229 patients who underwent 2-stage breast reconstruction between 2012 and 2021 was included in the study. The rate of expansion is estimated as the final expanded volume subtracted by the initial filling volume of the tissue expander over time elapsed. The native breast size was estimated using various preoperative breast measurements and the weight of mastectomy specimen (grams). Further stratified analysis evaluated patients separately based on postoperative radiation status.

RESULTS

Greater nipple-inframammary fold distance and faster tissue expander enlargement rate conferred decreased odds of developing capsular contracture ( P < 0.05). On stratified analysis, faster tissue expansion rate was not significant in the nonradiated cohort but remained a significant negative predictor in the radiation group (odds ratio, 0.996; P < 0.05). Cut-point analysis showed an expansion rate of <240 mL/mo and a nipple-inframammary fold value of <10.5 cm as conferring a greater risk of capsular contracture.

CONCLUSION

Smaller inframammary fold distance may be associated with a higher risk of capsular contracture. Slower expansion rates correlate with increased odds of contracture in patients undergoing adjuvant radiation. Breast geometry should be considered when risk stratifying various reconstruction approaches (implant vs autologous). In addition, longer delays between implant exchange and initial tissue expansion should be avoided if clinically feasible.

Current practice and provision of oncoplastic breast-conserving surgery in the UK: results of the ANTHEM national practice questionnaire

PURPOSE

Oncoplastic breast-conserving surgery (OPBCS) may be a better option than mastectomy ± immediate breast reconstruction (IBR) for women with breast cancer but studies directly comparing the techniques are lacking. We surveyed UK breast units to determine the current practice of OPBCS to inform the design of a future comparative study.

METHODS

An electronic survey was developed to explore the current practice of OPBCS. This included the local availability of volume displacement and/or replacement techniques; number of cases performed; contraindications and approach to contralateral symmetrisation. Summary data for each survey item were calculated and overall provision of care examined.

RESULTS

58 UK centres completed the survey, including 43 (74%) stand-alone breast and 15 (26%) combined breast/plastics units. Over 40% of units (n = 24) treated more than 500 cancers/year. Most units offered volume displacement techniques (TMs) (97%). Over two-thirds (n = 39. 67%) of units offered local perforator flaps (LPF). Approximately a half of units (10/19) not performing LPF were planning to introduce them in the next 12-24 months. A third (n = 19, 33%) of units routinely performed simultaneous contralateral symmetrisation mostly with two-surgeon operating. There were limited oncological restrictions to OPBCS with no contraindications for multifocal cancers in most centres; 65% of units (36/55) offered OPBCS for multicentric disease. Extensive DCIS was a contraindication in a minority of units.

CONCLUSIONS

OPBCS is widely available in the UK but contraindications and approaches to contralateral symmetrisation were variable. Work is now needed to prospectively evaluate the outcomes of OPBCS vs mastectomy ± IBR to support informed decision-making.

The Areola study: design and rationale of a cohort study on long-term health outcomes in women with implant-based breast reconstructions

BACKGROUND

Implant-based breast reconstructions contribute considerably to the quality of life of breast cancer patients. A knowledge gap exists concerning the potential role of silicone breast implants in the development of so called 'breast implant illness' and autoimmune diseases in breast cancer survivors with implant-based reconstructions. Breast implant illness (BII) is a constellation of non-specific symptoms reported by a small group of women with silicone breast implants.

METHODS/DESIGN

The Areola study is a multi-centre retrospective cohort study with prospective follow-up aiming to assess the risk of BII and autoimmune diseases in female breast cancer survivors with and without silicone breast implants. In this report, we set out the rationale, study design and methodology of this cohort study. The cohort consists of breast cancer survivors who received surgical treatment with implant-based reconstruction in six major hospitals across the Netherlands in the period between 2000 and 2015. As comparison group, a frequency-matched sample of breast cancer survivors without breast implants will be selected. An additional group of women who received breast augmentation surgery in the same years will be selected to compare their characteristics and health outcomes with those of breast cancer patients with implants. All women still alive will be invited to complete a web-based questionnaire covering health-related topics. The entire cohort including deceased women will be linked to population-based databases of Statistics Netherlands. These include a registry of hospital diagnostic codes, a medicines prescription registry and a cause-of-death registry, through which diagnoses of autoimmune diseases will be identified. Outcomes of interest are the prevalence and incidence of BII and autoimmune diseases. In addition, risk factors for the development of BII and autoimmune disorders will be assessed among women with implants.

DISCUSSION

The Areola study will contribute to the availability of reliable information on the risks of BII and autoimmune diseases in Dutch breast cancer survivors with silicone breast implants. This will inform breast cancer survivors and aid future breast cancer patients and their treating physicians to make informed decisions about reconstructive strategies after mastectomy.

REGISTRATION

This study is registered at ClinicalTrials.gov on June 2^nd 2022 (NCT05400954).

Changes in Spinal Alignment of Women Who Underwent Unilateral Mastectomy with Immediate Autologous Breast Reconstruction Compared To Mastectomy without Breast Reconstruction

INTRODUCTION

The impact of breast reconstruction on spinal alignment is not well studied, especially in immediate autologous breast reconstruction. Studies on body posture have shown greater asymmetry among those without reconstruction. This study compared the changes in spinal alignment pre- and post-operatively among women who underwent unilateral mastectomy without reconstruction (MA) versus immediate autologous breast reconstruction (IABR).

METHODS

A cross sectional, retrospective study analysed MA and IABRs performed from January 2007 to December 2017 and their pre- and post-operative anterior chest radiographs. The change in Cobb's angle (degrees) less than 1 year, 1 to 2 years, more than 2 years post-operatively were analysed using GE Healthcare Centricity Picture Archive and Communications Systems.

RESULTS

537 patients underwent mastectomy; 76 fulfilled the inclusion criteria (36 IABR, 40 MA). No significant difference existed between mean pre- and post-operative Cobb's angle change across all 3 groups, less than 1 year (MA 3.57±3.84, IABR 3.316±2.72, p=0.81), 1 to 2 years (MA 1.84±4.81, IABR -2.68±3.21, p=0.577) and more than 2 years post-operatively (MA -1.14±5.30, IABR -0.94±5.10, p=0.898). However raw data indicated IABR improved spinal alignment in the short and intermediate period post-operatively. Among IABR, free flap breast reconstruction improved spinal alignment compared to pedicled flaps [free flaps: 2.21±3.28, pedicled flaps: 0.01±3.67 (p=0.027)].

CONCLUSION

IABR has a positive impact on spinal alignment in early and intermediate post-operative period compared to MA, especially in women with larger breast volume. Physical benefits of IABR should be highlighted to improve patient's access to breast reconstruction globally.

Novel three-dimensional acellular dermal matrix for prepectoral breast reconstruction: First year in review with BRAXON®Fast

Implant-based breast reconstruction is part of breast cancer treatment, and increasingly optimized reconstructive procedures exploit highly biocompatible materials to ensure enhanced aesthetic-functional results. Acellular dermal matrices (ADMs) are collagen-based materials that made prepectoral implant placement possible, thanks to their bioactive antifibrosis action. Recently, the first three-dimensional ADM, BRAXON^®Fast, has been produced. Its 3D design represents the technological evolution of BRAXON^® ADM, a flat collagen matrix, and allows for a time-saving complete wrapping of the synthetic prosthesis, thus creating a total biological interface on the implant with patient's tissues. Here, we report our experience on the first 23 eligible patients who received BRAXON^®Fast-assisted prepectoral reconstruction. On a total of 27 breasts, the overall complication rate was 11.1%, including one minor seroma (3.7%), one case of necrosis (3.7%), and one implant removal due to infection. As new-generation devices, 3D ADMs showed an effective performance, allowing to reduce the overall exposure time for implant preparation and providing an optimal safety profile.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.

Short-term safety outcomes of mastectomy and immediate prepectoral implant-based breast reconstruction: Pre-BRA prospective multicentre cohort study

BACKGROUND

Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here.

METHODS

Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection.

RESULTS

Some 347 women underwent 424 immediate implant-based reconstructions at 40 centres. Most were single-stage direct-to-implant (357, 84.2 per cent) biological mesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction.

CONCLUSION

Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction.

Breast Radiotherapy after Oncoplastic Surgery—A Multidisciplinary Approach

Simple Summary

This article aims to review and summarize the current evidence for the role of oncoplastic breast surgery and the implications this may have on other therapies, such as radiotherapy and chemotherapy.

Abstract

Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.

≠Risk of breast implant removal after one- versus two-stage breast reconstructive surgery

BACKGROUND

To date, both one- and two-stage techniques are used in immediate 'implant-based breast reconstruction' (IBBR) after mastectomy. Because it is still unknown what technique offers the best clinical outcomes, a multicenter retrospective study was conducted to compare both breast reconstruction techniques.

METHODS

All patients, who underwent a mastectomy followed by immediate one- or two-stage IBBR during 2010 - 2016 were included. Our primary outcome measure was explantation of the 'tissue expander' (TE) and/ or implants within 60 days after breast reconstruction. Secondary outcomes were overall complication rate and secondary corrections.

FINDINGS

Among a total of 383 women, TE/ implant explantation rate was higher in one-stage (19.9%) than in two-stage (11.3%) treated patients (p = 0.082). Overall complication rate (35.7% and 19.9% respectively, p = 0.008) and secondary corrections (29.8% and 20.3% respectively, p = 0.156) were also higher in one-stage compared to two-stage IBBR respectively. However, explantation (OR = 1.55; 95%CI = 0.67-3.58, p = 0.301) and complication (OR = 1.85; 95%CI = 0.92-3.37, p = 0.084) rates were comparable in one- and two-stage IBBR in our stratified multivariate logistic regression analyses, when controlling for history of smoking, nipple-sparing mastectomy, neoadjuvant radiation therapy, and removed breast tissue weight. A remarkable outcome in this study is that women treated with prophylactic surgery were more likely to have an explantation of the TE/ implant after a one-stage IBBR (OR = 4.49; 95%CI = 1.10-18.3, p = 0.037) than two-stage IBBR. In contrast, no association between type of IBBR and risk of TE/implants removal was found among women with a therapeutic mastectomy (OR = 0.82; 95%CI = 0.24-2.79, p =  = 0.74).

CONCLUSION

One- and two-stage IBBR showed a comparable explantation and complication rate in our retrospective study. In one-stage IBBR more secondary corrections were detected. In addition, women who have to decide on a prophylactic mastectomy should be aware of a significantly higher risk of explantation of their implant after one-stage IBBR.

Best-BRA (Is subpectoral or prepectoral implant placement best in immediate breast reconstruction?): a protocol for a pilot randomised controlled trial of subpectoral versus prepectoral immediate implant-based breast reconstruction in women following mastectomy

BACKGROUND

Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques.

METHODS AND ANALYSIS

Best-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN10081873.

Microsurgical autologous breast reconstruction in the midst of a pandemic: A single-unit COVID-19 experience

Introduction

COVID-19 has disrupted the provision of breast reconstructive services throughout the UK. Autologous free flap breast reconstruction was restarted in our unit on 3 June 2020. We aimed to compare the unit's performance of microsurgical autologous breast reconstruction in the “post-COVID” period compared with the exact time period in the preceding year.

Methods

We retrospectively reviewed prospectively collected data in the “pre-COVID” (from 3 June 2019 to 31 December 2019) and “post-COVID” period (from 3 June 2020 to 31 December 2020). Patient demographics included age, body mass index, co-morbidities, Anaesthesiologists (ASA) grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, reconstruction timing, number of pedicles, contralateral symmetrisation and other procedures.

dependant variables were ischaemic time, operative time, mastectomy weight, flap weight, length of stay, return to theatre and complication rates. The number of trainers and trainees present in theatre was recorded and analysed.

Results

Fewer DIEP flaps were performed in the “post-COVID” period (45 vs. 29). No significant difference was observed in mastectomy resection weight, but flap weight was significantly increased. No significant difference was found in ischaemic time as well.

The postoperative length of stay was significantly reduced. No significant difference was found in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. No cases of venous thromboembolism or flap failures were recorded.

The mean number of trainers and trainees, and the trainee-to-trainer ratio was not found to be significantly different between cohorts.

Conclusion

Although fewer cases were performed, autologous breast reconstruction was safely delivered throughout the COVID-19 pandemic in the first wave without affecting training.

Protocol for a national cohort study to explore the long-term clinical and patient-reported outcomes and cost-effectiveness of implant-based and autologous breast reconstruction after mastectomy for breast cancer: the brighter study

INTRODUCTION

Breast reconstruction (BR) is offered to improve quality of life for women with breast cancer undergoing mastectomy. As most women will be long-term breast cancer survivors, high-quality information regarding the long-term outcomes of different BR procedures is essential to support informed decision-making. As different techniques vary considerably in cost, policymakers also require high-quality cost-effectiveness evidence to inform care. The Brighter study aims to explore the long-term clinical and patient-reported outcomes (PROs) of implant-based and autologous BR and use health economic modelling to compare the long-term cost-effectiveness of different reconstructive techniques.

METHODS AND ANALYSIS

Women undergoing mastectomy and/or BR following a diagnosis of breast cancer between 1 January 2008 and 31 March 2009 will be identified from hospital episode statistics (HES). Surviving women will be contacted and invited to complete validated PRO measures including the BREAST-Q, EQ-5D-5L and ICECAP-A, or opt out of having their data included in the HES analysis. Long-term clinical outcomes will be explored using HES data. The primary outcome will be rates of revisional surgery between implant-based and autologous procedures. Secondary outcomes will include rates of secondary reconstruction and reconstruction failure. The long-term PROs of implant-based and autologous reconstruction will be compared using BREAST-Q, EQ-5D-5L and ICECAP-A scores. Multivariable regression will be used to examine the relationship between long-term outcomes, patient comorbidities, sociodemographic and treatment factors. A Markov model will be developed using HES and PRO data and published literature to compare the relative long-term cost-effectiveness of implant-based and autologous BR.

ETHICS AND DISSEMINATION

The Brighter study has been approved by the South-West -Central Bristol Research Ethics Committee (20/SW/0020), and the Confidentiality Advisory Group (20/CAG/0021). Results will be published in peer-reviewed journals and presented at national meetings. We will work with the professional associations, charities and patient groups to disseminate the results.

Awareness and Acceptability of Breast Reconstruction Among Women With Breast Cancer: A Prospective Survey

PURPOSE

Quality of life has become an integral aspect of the management of breast cancer. Many women still need to undergo a modified radical mastectomy (MRM). Factors affecting the choice a woman makes to undergo breast reconstruction (BR) are unclear and are hypothesized to be influenced by socioeconomic factors. We conducted a survey to evaluate the awareness and acceptability of BR among women with breast cancer at our institution.

METHODS

A novel questionnaire was designed and served to 3 groups of women: planned for MRM, follow up (FU) post-MRM, and FU post breast-conserving surgery.

RESULTS

Responses were analyzed from 492 women. Of these, 280 (56.91%) were planned for MRM and 212 (43.08%) women were on FU. Almost 45% women were older than 50 years of age, and literacy rate was 87.6%. More than 70% were homemakers and 15 women (3%) were unmarried. The aspects evaluating awareness of BR suggested that 251 (51.01%) women had knowledge about BR. Major source of information was the surgeon (45.81%) and media (32.87%). About 80% women on FU post-MRM did not want reconstruction, and 55% did not opt for BR as they had coped with the mastectomy and did not feel the need for BR. Only 6% cited family or financial reasons and 10% cited recurrence concerns. Among women planned for surgery, 65.71% had not considered BR. When questioned, 25 (12.88%) felt influenced by cost, 102 (52.58%) felt they did not need it, and 20 (10.31%) were worried it would affect treatment.

CONCLUSION

Our study shows high awareness regarding BR, but only 27.89% women opt for BR independent of economic issues. We recommend all patients should be counseled about the reconstructive options when their MRM is planned.

Long-term outcomes of two-stage, immediate and delayed breast reconstruction with polyurethane-covered versus textured implants: protocol of a prospective, multicentre randomised controlled trial (TIPI trial)

INTRODUCTION

Two-stage implant-based breast reconstruction is the most commonly performed postmastectomy reconstructive technique. During the first stage, a tissue expander creates a sufficiently large pocket for the definite breast implant placed in the second stage. Capsular contracture is a common long-term complication associated with implant-based breast reconstruction, causing functional complaints and often requiring reoperation. The exact aetiology is still unknown, but a relationship between the outer surface of the implant and the probability of developing capsular contracture has been suggested. The purpose of this study is to determine whether polyurethane-covered implants result in a different capsular contracture rate than textured implants.

METHODS AND ANALYSIS

The Textured Implants versus Polyurethane-covered Implants (TIPI) trial is a multicentre randomised controlled trial with a 1:1 allocation rate and a follow-up of 10 years. A total of 321 breasts of female adults undergoing a two-stage breast reconstruction will be enrolled. The primary outcome is capsular contracture at 10-year follow-up which is graded with the modified Baker classification. It is analysed with survival analysis using a frailty model for clustered interval-censored data, with both an intention-to-treat and per-protocol approach. Secondary outcomes are other complication rates, surgical revision rate, patient satisfaction and quality of life and user-friendliness. Outcomes are measured 2 weeks, 6 months, 1, 2, 3, 5 and 10 years postoperatively. Interim analysis is performed when 1-year, 3-year and 5-year follow-up is completed.

ETHICS AND DISSEMINATION

The trial has been reviewed and approved by the Medical Research Ethics Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2018-126) and locally by each participating centre. Written informed consent will be obtained from each study participant. The results will be disseminated by publication in peer-reviewed journals.

TRIAL REGISTRATION

NTR7265.

Biological and synthetic mesh assisted breast reconstruction procedures: Joint guidelines from the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons

These guidelines have been produced with the involvement of the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons. Recommendations have been derived after a review of published data regarding the use of acellular dermal matrix (ADM), biological and synthetic mesh in breast reconstruction. The guidelines represent a consensus opinion on the optimal management of patients having biological or synthetic mesh assisted breast reconstruction informed by peer-review publications. The Guidelines should be used to inform clinical decision making. Ultimately, members of the MDT remain responsible for the treatment of patients under their care.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

Protocol for a mixed-method study to inform the feasibility of undertaking a large-scale multicentre study comparing the clinical and patient-reported outcomes of oncoplastic breast conservation as an alternative to mastectomy with or without immediate breast reconstruction in women unsuitable for standard breast-conserving surgery (the ANTHEM Feasibility Study)

INTRODUCTION

Approximately 40% of the 55 000 women diagnosed with breast cancer each year in the UK undergo mastectomy because they are considered unsuitable for standard breast-conserving surgery (BCS) due to tumour size or multiple tumour foci. Mastectomy can significantly impact women's quality of life, and only one in four women currently undergo immediate breast reconstruction (IBR).Level 2 oncoplastic breast-conserving surgery (OPBCS) combines removing the cancer with a range of plastic surgical volume replacement (eg, local perforator flaps) and volume displacement techniques (eg, therapeutic mammaplasty) that can extend the role of BCS and may allow some women not suitable for standard BCS to avoid mastectomy. High-quality research to determine whether OPBCS offers a safe and effective alternative to mastectomy±IBR is currently lacking. Preliminary work is needed to ensure a future large-scale study is feasible and well designed and addresses questions important to patients and the National Health Service.

METHODS AND ANALYSIS

Mixed methods will be used to inform feasibility and design of a future large-scale study comparing the clinical effectiveness and cost-effectiveness of OPBCS and mastectomy±IBR. It will have four parts: (1) a National Practice Questionnaire to determine current practice and provision of oncoplastic breast and reconstructive surgery in the UK; (2) a pilot multicentre prospective cohort study to explore the proportion of patients choosing OPBCS versus mastectomy, the proportion in OPBCS is successful and clinical and patient-reported outcomes of different techniques at 3 and 12 months postsurgery; (3) a qualitative interview study to explore patients' attitudes to different procedures, rationale for decision-making and perceptions of outcomes; and (4) design of the future study.All centres offering OPBCS and mastectomy in the UK will be invited to participate. Recruitment is planned to commence winter 2020 and continue for 12 months.

ETHICS AND DISSEMINATION

The study has ethical approval from the Wales Research Ethics Committee 6 National Research Ethics Service (REC Ref 20/WA/0225). Results will be presented at national and international meetings and published in peer-reviewed journals. We will work with patients to develop lay summaries and share these through patient groups and breast cancer charities.

TRIAL REGISTRATION NUMBER

ISRCTN18238549.

Cost-effectiveness of single-use negative-pressure therapy compared with standard care for prevention of reconstruction failure in prepectoral breast reconstruction

Background

Single-use negative-pressure wound therapy (sNPWT) has been reported to reduce the incidence of reconstruction failure in prepectoral breast reconstruction compared with standard surgical dressings. The aim of this economic evaluation was to investigate the cost-effectiveness of sNPWT compared with standard care for the prevention of reconstruction failure in prepectoral breast reconstruction in the UK.

Method

A decision tree model was used to estimate the expected cost and effectiveness per patient. Effectiveness was measured both by the number of reconstruction failures avoided and the gain in quality-adjusted life-years (QALYs). The baseline incidence of reconstruction failure (8.6 per cent) was taken from a recently published study of 2655 mastectomies in the UK. The effectiveness of sNPWT used results from a clinical study comparing sNPWT with standard dressings. Previously published utility weights were applied. The cost of reconstruction failure was estimated from detailed resource data from patients with reconstruction failure, applying National Health Service reference costs. One-way, probabilistic, scenario and threshold analyses were conducted.

Results

The undiscounted cost per patient associated with reconstruction failure was estimated to be £23 628 (£22 431 discounted). The use of sNPWT was associated with an expected cost saving of £1706 per patient, an expected increase in QALYs of 0.0187 and an expected 0.0834 reconstruction failures avoided. Cost-effectiveness acceptability analysis demonstrated that, at a threshold of £20 000 per QALY, 99.94 per cent of the simulations showed sNPWT to be more cost-effective than standard care.

Conclusion

Among patients undergoing immediate prepectoral breast reconstruction, the use of sNPWT is more cost-effective than standard dressings.

Patient-reported outcomes of immediate implant-based breast reconstruction with and without biological or synthetic mesh

BACKGROUND

Biological and synthetic meshes may improve the outcomes of immediate implant-based breast reconstruction (IBBR) by facilitating single-stage procedures and improving cosmesis. Supporting evidence is, however, limited. The aim of this study was to explore the impact of biological and synthetic mesh on patient-reported outcomes (PROs) of IBBR 18 months after surgery.

METHODS

Consecutive women undergoing immediate IBBR between February 2014 and June 2016 were recruited to the study. Demographic, operative, oncological and 3-month complication data were collected, and patients received validated BREAST-Q questionnaires at 18 months. The impact of different IBBR techniques on PROs were explored using mixed-effects regression models adjusted for clinically relevant confounders, and including a random effect to account for clustering by centre.

RESULTS

A total of 1470 participants consented to receive the questionnaire and 891 completed it. Of these, 67 women underwent two-stage submuscular reconstructions. Some 764 patients had a submuscular reconstruction with biological mesh (495 women), synthetic mesh (95) or dermal sling (174). Fourteen patients had a prepectoral reconstruction. Compared with two-stage submuscular reconstructions, no significant differences in PROs were seen in biological or synthetic mesh-assisted or dermal sling procedures. However, patients undergoing prepectoral IBBR reported better satisfaction with breasts (adjusted mean difference +6.63, 95 per cent c.i. 1.65 to11.61; P = 0.009). PROs were similar to those in the National Mastectomy and Breast Reconstruction Audit 2008-2009 cohort, which included two-stage submuscular procedures only.

CONCLUSION

This study found no difference in PROs of subpectoral IBBR with or without biological or synthetic mesh, but provides early data to suggest improved satisfaction with breasts following prepectoral reconstruction. Robust evaluation is required before this approach can be adopted as standard practice.

Development of an online research platform for use in a large-scale multicentre study

Background

Participation in research can be beneficial for patients and healthcare providers, but may prove demanding at patient, clinician and organizational levels. Patient representatives are supportive of online research to overcome these challenges. The aim of this pilot study was to develop an online recruitment platform and test its feasibility and acceptability while evaluating the accuracy of participant-reported data.

Methods

The online research platform was developed in a 1-day ‘hackathon’ with a digital design company. Women who underwent implant-based breast reconstruction in 2011–2016 were invited by letter containing the web address (URL) of the study site and their unique study number. Once online, participants learned about the study, consented, entered data on demographics, treatment received and patient-reported outcome measures (BREAST-Q™), and booked an appointment for a single hospital visit for three-dimensional surface imaging (3D-SI). Real-time process evaluation was performed. The primary endpoint was recruitment rate.

Results

The recruitment rate was 40 per cent. Of the 100 women, 50 logged on to the platform and 40 completed the process through to 3D-SI. The majority of discontinuations after logging on occurred between consenting and entering demographics (3 women, 6 per cent), and between completing the BREAST-Q and booking an appointment for 3D-SI using the online calendar (3 women, 6 per cent). All women completed the online BREAST-Q™ once started. Participants took a median of 23 minutes to complete the online process. Patient-reported clinical data were accurate in 12 of 13 domains compared with electronic records (95 per cent concordance). Process evaluation demonstrated acceptability.

Conclusion

The results of this pilot demonstrate the online platform to be acceptable, feasible, and accurate for this population from a single institution. The low-burden design may enable participation from centres with less research support and participants from hard-to-reach groups or dispersed geographical locations, but with online access.

Decisional conflict in breast cancer patients considering immediate breast reconstruction

Background

Breast cancer (BC) patients who are treated with mastectomy are frequently offered immediate breast reconstruction. This study aimed to assess decisional conflict in patients considering immediate breast reconstruction, and to identify factors associated with clinically significant decisional conflict (CSDC).

Methods

Baseline data of a multicenter randomized controlled trial evaluating the impact of an online decision aid for BC patients considering immediate breast reconstruction after mastectomy were analyzed. Participants completed questionnaires assessing sociodemographic and clinical characteristics, decisional conflict and other patient-reported outcomes related to decision-making such as breast reconstruction preference, knowledge, information resources used, preferred involvement in decision-making, information coping style, and anxiety. Multivariable logistic regression analysis was performed to identify factors associated with CSDC (score > 37.5 on decisional conflict).

Results

Of the 250 participants, 68% experienced CSDC. Patients with a slight preference for breast reconstruction (odds ratio (OR) = 6.19, p < .01), with no preference for or against breast reconstruction (OR = 11.84, p < .01), and with a strong preference for no breast reconstruction (OR = 5.20, p < .05) were more likely to experience CSDC than patients with a strong preference for breast reconstruction. Furthermore, patients with more anxiety were more likely to experience CSDC (OR = 1.03, p = .01).

Conclusion

A majority of BC patients who consider immediate breast reconstruction after mastectomy experience clinically significant decisional conflict. The findings emphasize the need for decision support, especially for patients who do not have a strong preference for breast reconstruction.

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A majority of patients considering immediate breast reconstruction experience decisional conflict.

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Patients without a strong preference for breast reconstruction are more likely to experience decisional conflict.

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Patients with more anxiety are more likely to experience decisional conflict.

Comparison of subpectoral versus dual-plane implant based immediate breast reconstruction after nipple-areola sparing mastectomy

BACKGROUND

Selection of implant pocket and size is a dilemma for surgeons especially if radiation therapy is envisaged after implant based immediate breast reconstruction (IBR). The aim of this study is to compare complication rates between subpectoral and the dual plane polyglactin mesh supported IBR after nipple-areola sparing mastectomy.

PATIENTS AND METHOD

Reconstructive analysis of 208 breasts of 190 patients with breast cancer undergoing implant based IBR at a single university hospital were evaluated. The patients were reconstructed with either dual-plane polyglactin mesh supported (n=91) or subpectoral (n=117) implant based IBR after nipple-areola sparing mastectomy. Demographic data, and postoperative complications were compared.

RESULTS

The mean age was 43.3 years. Early complications encountered in 12% (n=25) and late complications occurred in 18% (n=37) of breasts. Both early (13,7% vs 9.9%, P=0.406) and late complications (24.8% vs 8.8%, P=0.003) were more common in subpectoral group, but only late complication occurrence rate was statistically significant. Capsular contracture (P=0.000), inframammary fold problems (P=0.010), bottoming-out (P=0.370), mechanical shift (P=0.036) and animation deformity (P=0.007) were all more common in subpectoral group. Only rippling deformity (P=0.011) was more common in dual plane group.

CONCLUSIONS

Dual plane IBR has acceptable complication rates compared to subpectoral IBR. It is associated with less capsular contracture, fewer animation and bottoming-out deformity and better inframammary fold appearance.

The feasibility and safety of immediate breast reconstruction in the COVID-19 era

The coronavirus disease-2019 pandemic has had a significant impact on the delivery of surgical services, particularly reconstructive surgery. This article examines the current evidence to assess the feasibility of recommencing immediate breast reconstruction services during the pandemic and highlights considerations required to ensure patient safety.

Costs of Early Invasive Breast Cancer in England Using National Patient-Level Data

OBJECTIVES

This study aimed to use patient-level data to provide up-to-date estimates of early invasive breast cancer care costs by stage in England and to explore to what extent these costs varied based on patients' ages and geographic regions.

METHODS

This study identified women aged 50 years and older who had been diagnosed with early invasive breast cancer between January 1, 2014, and December 31, 2015, using linked cancer registrations and routine hospital data sets generated from the usual care for all National Health Service trusts in England. Cost estimates were derived from hospital records in Hospital Episodes Statistics with additional chemotherapy and radiotherapy information from the national data sets. We fitted general linear regression models to analyze the cost data. The model that best fit the data was selected using the model selection criteria of Akaike information criterion.

RESULTS

55 662 women with early invasive breast cancer in England were included. The generalized linear model with log-gamma distribution fit the data best. The costs of breast cancer care for 1 year after diagnosis were strongly dependent on stage at diagnosis, controlling for other covariates. The estimated average per-patient hospital-related costs were £5167 at stage I, £7613 at stage II, and £13 330 at stage IIIA. Costs decreased with increasing age (P < .001) and varied across region (P < .001), deprivation level (P < .001), referral source (P < .01), presence of comorbidities (P< .001), and tumor receptor (ER/PR/HER2) status (P < .001).

CONCLUSIONS

In England, the costs of breast cancer care increased with advancing stage of the disease at diagnosis. Breast cancer costs varied by age and geographic region.

Reconstructive trends following mastectomies in Scotland: A comparison with England

INTRODUCTION

In England there has been a substantial increase in the use of immediate implant-based reconstruction, accounting for over half of all immediate reconstructions (IR). Less than one third of patients in England undergo autologous reconstruction IR. Our aim was to examine IR trends in Scotland.

METHODS

Data was extracted from the Scottish Morbidity Record held at the Information Services Division of the NHS National Services Scotland. All patients discharged from Scottish hospitals between 2011 and 2016 who had a diagnosis of breast cancer including DCIS and underwent mastectomy were identified. Patients undergoing IR were identified by coding at the time of mastectomy to identify who had IR and what method was used.

RESULTS

Between 2011 and 2016, 7358 patients underwent a mastectomy for breast cancer. 1845 patients (25%) had an IR. The percentage of patients undergoing IR increased from 22% in 2011 to 26% in 2016. The dominant annual procedure type was autologous reconstruction (free flap and pedicled flaps), accounting for 58% in 2011 and 54% in 2016. Pedicled flaps alone decreased from 40% in 2011 to 28% in 2016 and free flaps increased from 18% in 2011 to 26% in 2016. Implant based reconstruction rates were broadly consistent, 37% in both 2011 and 2016. Pedicled flaps with implant reconstruction decreased from 13% in 2011 to 5% in 2016.

CONCLUSIONS

Autologous reconstruction (with increasing trend for free flaps procedures) remains a constant preferred technique for IR in Scotland, accounting for over half of IR performed.

The Impact of Radiotherapy on Patient-reported Outcomes of Immediate Implant-based Breast Reconstruction With and Without Mesh

OBJECTIVE

To explore the impact of PMRT on PROs of IBBR performed with and without mesh.

SUMMARY OF BACKGROUND DATA

PMRT is increasingly given to improve breast cancer outcomes but can adversely impact complications after IBBR. Little; however, is known about the impact of PMRT on the PROs of IBBR, especially when mesh is used.

METHODS

The implant Breast Reconstruction evAluation prospective cohort study recruited consecutive women undergoing immediate IBBR from 81 UK breast and plastic surgical units. Demographic, operative, oncological, and 3-month complication data were collected, and patients consented to receive validated PRO questionnaires at 18-months. The association between IBBR, PMRT, and PROs were investigated using mixed-effects regression models adjusted for clinically-relevant confounders and including a random-effect to account for potential clustering by center RESULTS:: A total of 1163 women consented to receive 18-month questionnaires of whom 730 (63%) completed it. Patients undergoing PMRT (214 patients) reported worse PROs in 3 BREAST-Q domains: satisfaction with breasts [-6.27 points, P = 0.008, 95% confidence interval (CI) (-10.91, -1.63)], satisfaction with outcome [-7.53 points, P = 0.002, CI (-12.20, -2.85)] and physical well-being [-6.55 points, P < 0.001, CI (-9.43, -3.67)]. Overall satisfaction was worse in the PMRT group [OR 0.497, P = 0.002, CI (0.32, 0.77)]. These effects were not ameliorated by mesh use.

CONCLUSIONS

PMRT may adversely affect PROs after IBBR irrespective of whether mesh is used. These findings should be discussed with all patients considering IBBR and when indications for PMRT are borderline to enable informed decision-making regarding oncological and reconstructive treatment options.

TRIAL REGISTRATION

ISRCTN37664281.

A scoring system for 3D surface images of breast reconstruction developed using the Delphi consensus process

Introduction

Evaluation of aesthetics after breast reconstruction is challenging. In the absence of an objective measurement, panel assessment is widely adopted. Heterogeneity of scales and poor internal consistency make comparison difficult. Development and validation of an expert panel scale using a Delphi consensus process is described. It was designed specifically for use as the gold standard for development of an objective evaluation tool using 3-Dimensional Surface Imaging (3D-SI).

Materials and methods

20 items relating to aesthetic assessment were identified for consideration in the Delphi consensus process. Items were selected for inclusion in the definitive panel scale by iterative rounds of voting according to importance, consensus discussion, and a final vote. The Delphi-derived scale was tested on a clinical research series for intra- and inter-panellist, and intra-panel reliability, and correlation with Patient Reported Outcome Measures (PROMs).

Results

61 surgeons participated in the Delphi process. Oncoplastic and plastic surgeons were represented. The Delphi-derived scale included symmetry, volume, shape, position of breast mound, nipple position, and a global score. Intra-panellist reliability ranged from poor to almost perfect (wκ<0to0.86), inter-rater reliability was fair (ICC range 0.4–0.5) for individual items and good (ICC0.6) for the global score, intra-panel reliability was moderate to substantial (wκ0.4–0.7), and correlation with PROMs was moderate (r = 0.5p < 0.01).

Conclusions

The Delphi-derived panel evaluation is at least as good as other scales in the literature and has been developed specifically to provide expert evaluation of aesthetics after breast reconstruction. The logistical constraints of panel assessment remain, reinforcing the need to develop an objective evaluation method.

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Aesthetic outcome has well described influence on long term quality of life

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Many scoring systems exist, each with methodological flaws.

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A Delphi consensus process was used to derive a contemporary panel scoring system for expert aesthetic evaluation

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The scoring system was tested and performed well on a series of images of women who have undergone breast reconstruction

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

BACKGROUND

In both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend.

OBJECTIVE

The aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil.

METHODS

Online survey with physical therapists in both countries. We asked about physical therapists' clinical practice.

RESULTS

181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2-4 weeks ROM was unrestricted; at 1-3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities.

CONCLUSION

Only half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery.

Spontaneously generated large adipose flaps in vivo tissue engineering chambers

AIM

Previous experiments using our in vivo tissue engineering chamber (TEC) model demonstrated that adipose flap was spontaneously generated without the need for adipocyte or stem cell implantation. The purposes of the present study are to clarify 1) the reproducibility of this method to create adipose flaps, 2) the time-course of adipogenesis, and 3) the long-term stability of the adipose flap generated.

METHODS

The chambers that afforded a protected space for tissue growth were implanted into the groins of rabbits. A vascular pedicle as the vascular source of newly formed tissue, a collagen sponge as a scaffold, and platelet-rich plasma (PRP) and fibroblast growth factor (bFGF) as growth factors were contained within the chamber. There were three experimental groups according to the implantation period of the chamber; Group 4 w, Group 8 w, and Group 12 w (n = 5 in each group).

RESULTS

The percent volumes of the combined adipose/pedicle tissue compared with the total volume of the generated tissue were 14.8% (0.437 cm³/2.96 cm³), 47% (0.87 cm³/1.85 cm³) and 80% (1.82 cm³/2.27 cm³) in Groups 4 w, 8 w, and 12 w, respectively. When a 12-week adipose flap was transferred outside the chamber on its vascular pedicle and retained for a further five months, it became more like mature adipose tissue and had increased fat density.

CONCLUSION

Adipose flaps were spontaneously generated in vivo in TECs at 12 weeks with reproducibility and showed long-term stability outside the chamber following pedicle transfer. The tissue-engineered adipose flap will contribute to breast reconstruction and augmentation without donor-site morbidity.

Perceived barriers to randomised controlled trials in breast reconstruction: obstacle to trial initiation or opportunity to resolve? A qualitative study

BACKGROUND

Implant-based breast reconstruction (IBBR) is the most commonly performed breast reconstruction technique worldwide but the technique is evolving rapidly. High-quality evidence is needed to support practice. Randomised controlled trials (RCTs) provide the best evidence but can be challenging to conduct. iBRA is a four-phased study which aimed to inform the feasibility, design and conduct of an RCT in IBBR. In phase 3, the randomisation acceptability study, an electronic survey and qualitative interviews were conducted to explore professionals' perceptions of future trials in IBBR. Findings from the interviews are presented here.

METHODS

Semi-structured qualitative interviews were undertaken with a purposive sample of 31 health professionals (HPs) who completed the survey to explore their attitudes to the feasibility of potential RCTs in more detail. All interviews were transcribed verbatim and data were analysed thematically using constant comparative techniques. Sampling, data collection and analysis were undertaken iteratively and concurrently until data saturation was achieved.

RESULTS

Almost all HPs acknowledged the need for better evidence to support the practice of IBBR and most identified RCTs as generating the highest-quality evidence. Despite highlighting potential challenges, most participants supported the need for an RCT in IBBR. A minority, however, were strongly opposed to a future trial. The opposition and challenges identified centred around three key themes; (i) limited understanding of pragmatic study design and the value of randomisation in minimising bias; (ii) clinician and patient equipoise and (iii) aspects of surgical culture and training that were not supportive of RCTs.

CONCLUSION

There is a need for well-designed, large-scale RCTs to support the current practice of IBBR but barriers to their acceptability are evident. The perceived barriers to RCTs in breast reconstruction identified in this study are not insurmountable and have previously been overcome in other similar surgical trials. This may represent an opportunity, not only to establish the evidence base for IBBR, but also to improve engagement in RCTs in breast surgery in general to ultimately improve outcomes for patients.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN37664281.

Experiences of implant loss after immediate implant-based breast reconstruction: qualitative study

BACKGROUND

Immediate implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK, but almost one in ten women experience implant loss and reconstructive failure after this technique. Little is known about how implant loss impacts on patients' quality of life. The first phase of the Loss of implant Breast Reconstruction (LiBRA) study aimed to use qualitative methods to explore women's experiences of implant loss and develop recommendations to improve care.

METHODS

Semistructured interviews were conducted with a purposive sample of women who experienced implant loss after immediate IBBR, performed for malignancy or risk reduction across six centres. Interviews explored decision-making regarding IBBR, and experiences of implant loss and support received. Thematic analysis was used to explore the qualitative interview data. Sampling, data collection and analysis were undertaken concurrently and iteratively until data saturation was achieved.

RESULTS

Twenty-four women were interviewed; 19 had surgery for malignancy and five for risk reduction. The median time between implant loss and interview was 42 (range 22-74) months. Ten women had undergone secondary reconstruction, two were awaiting surgery, and 12 had declined further reconstruction. Three key themes were identified: the need for accurate information about the risks and benefits of IBBR; the need for more information about 'early-warning' signs of postoperative problems, to empower women to seek help; and better support following implant loss.

CONCLUSION

Implant loss is a devastating event for many women. Better preoperative information and support, along with holistic patient-centred care when complications occur, may significantly improve the experience and outcome of care.

Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction

BACKGROUND

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.

METHODS

The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.

RESULTS

A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.

CONCLUSION

TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.

Reconstructive utilisation and outcomes following mastectomy surgery in women with breast cancer treated in England

INTRODUCTION

Breast cancer usually necessitates breast-conserving surgery or mastectomy, which adversely affect appearance and wellbeing. Immediate reconstruction restores the breast mound but its availability and efficacy are uncertain.

MATERIALS AND METHODS

Two discrete datasets were used to evaluate mastectomies in England: Hospital Episode Statistics to measure overall activity and variation over time and by region and a national prospective audit to evaluate immediate reconstruction decision making, complication rates and patient-reported satisfaction with information, choice and outcomes.

RESULTS

The 2005-08 Hospital Episode Statistics analyses identified 20% breast-conserving surgery reoperation rates nationally, frequently involving mastectomy. Rates were higher with in-situ disease present (30% vs 18%) and varied across NHS trusts (10th-90th centiles 12-30%). The 2008-09 national audit examined 18,216 women. The 19% immediate reconstruction rate varied regionally (9-43%), as did 2006-09 Hospital Episode Statistics data (8-32%). A total of 48% of women were offered immediate reconstruction, again varying regionally (24-75%). Offer likelihood fell with increasing age. National immediate reconstruction rates increased from 10% to 23% from 2000 to 2014, but regional variation persisted. Despite high care satisfaction, just 65% of mastectomy patients received the right amount of reconstructive information (90% for immediate reconstruction). Women from deprived areas experienced higher complication rates. Flap-based immediate reconstruction led to greater satisfaction with breast area appearance, emotional and sexual wellbeing and overall outcome than mastectomy; implant-only immediate reconstruction scored no better.

CONCLUSION

Reconstruction is central to improving breast cancer outcomes. The differential outcomes and persistent regional inequalities identified should facilitate decision making, support improved access to all reconstructive options and inform the development of an optimal patient pathway.

The Pre-BRA (pre-pectoral Breast Reconstruction EvAluation) feasibility study: protocol for a mixed-methods IDEAL 2a/2b prospective cohort study to determine the safety and effectiveness of prepectoral implant-based breast reconstruction

INTRODUCTION

Implant-based breast reconstruction is the most commonly performed reconstructive technique worldwide. Subpectoral reconstruction with mesh is the current standard of care but new prepectoral techniques have recently been introduced. Prepectoral breast reconstruction (PPBR) may improve outcomes for patients but robust evaluation is required. Randomised clinical trials (RCTs) are ideally needed but the short-term safety of PPBR is yet to be established; the technique and its indications are evolving and it has yet to be adopted by a sufficient number of surgeons for an RCT to be feasible.The Pre-BRA study aims to determine the feasibility of using mixed-methods within an IDEAL 2a/2b (IDEAL, Idea-Development-Exploration-Assessment-Long-term) study to explore the short-term safety of PPBR and determine when the technique is sufficiently stable for evaluation in a pragmatic RCT.

METHODS AND ANALYSIS

Pre-BRA is an IDEAL stage 2a/2b prospective multicentre cohort study with embedded qualitative research.Consecutive patients electing to undergo immediate PPBR at participating centres will be invited to participate. Demographic, operative, oncology and complication data will be collected and patient-reported outcomes will be assessed at baseline, 3 and 18 months postoperatively. The primary safety endpoint will be implant loss at 3 months.Surgeons performing PPBR will be asked to complete questionnaires regarding their practice and report any modifications made to the procedure or learning arising from complications via free-text response fields on electronic case-report forms. Semistructured will explore surgeons' experiences in detail to identify emerging best practice. This will be fed back to participating surgeons to promote shared learning.The Pre-BRA study will aim to recruit 341 patients from 30 to 40 UK centres over a 12-month period. Recruitment will commence Spring 2019.

ETHICS AND DISSEMINATION

The study has full ethical approval from OXFORD-B South Central Committee Ref:19/SC/0129. Results will be presented at national and international meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN11898000; Pre-results.

International development and implementation of a core measurement set for research and audit studies in implant-based breast reconstruction: a study protocol

INTRODUCTION

Outcome reporting in research studies of breast reconstruction is inconsistent and lacks standardisation. The results of individual studies therefore cannot be meaningfully compared or combined limiting their value. A core outcome set (COS) has been developed to address these issues and identified 11 key outcomes to be measured and reported in all future research and audit studies in reconstructive breast surgery (RBS). A COS represents what key outcomes should be measured. The next step is to determine how and when this should be done. The aim of this study is to develop a core measurement set (CMS) for use in research and audit studies in implant-based breast reconstruction.

METHODS AND ANALYSIS

The CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials initiative (COMET) and COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) group for the selection of outcome measurement instruments (OMIs) for relevant outcome domains included in the RBS COS. This will involve three phases with strategies to promote implementation as a final additional phase. The phases are (1) conceptual considerations in which the target population, procedures and settings are defined; (2) systematic reviews to identify existing clinical, patient-reported and cosmetic OMIs and, if appropriate, assess their quality using COSMIN methodology; (3) a modified Delphi process including sequential Delphi surveys involving approximately 100 healthcare professionals and a face to face consensus meeting to agree and ratify which outcome definitions and OMIs should be used and standardised time points for assessment; (4) strategies to promote dissemination and adoption of the CMS.

ETHICS AND DISSEMINATION

Ethical approval has been granted by University of Bristol Faculty Research Ethics Committee FREC ID 60221. Dissemination strategies will include scientific meeting presentations and peer-reviewed journal publications. Implementation activities will include engagement with journal editors and funders to promote uptake and use of the CMS.

Significantly reducing implant loss rates in immediate implant-based breast reconstruction: A protocol and completed audit of quality assurance

INTRODUCTION

Immediate implant-based breast reconstruction (IBR) rates have increased considerably with the advent of acellular dermal matrices. Implant loss is a significant complication and is costly to patients and the NHS. National Mastectomy and Breast Reconstruction Audit and Implant-Based Breast Reconstruction Audit data have demonstrated national implant loss rate of 9% at 3 months. National Oncoplastic Guidelines for Best Practice cite a < 5% target. We aimed to reduce implant loss by introducing a protocol with pre-, intra- and post-operative interventions.

METHODS

Audit of IBR at a single oncoplastic breast unit was commenced and implant loss at 3 months was recorded (May 2012-July 2014). Patients were identified from a prospectively maintained database, and case notes were examined by identifying factors associated with implant loss. A team involving microbiology, theatre staff, infection control and surgeons was established. A novel, evidence-based intervention bundle, including more than 25 protocol changes, was introduced. Prospective re-audit of IBR (April 2015-December 2017) was completed following introduction of the new protocol and implant loss was recorded at 3 months.

RESULTS

The first retrospective audit of 77 reconstructions (54 patients) demonstrated 11 implant losses at 3 months (14%). Re-audit, post-intervention, comprised 129 reconstructions (106 patients) with no implant loss at 3 months. Fisher's exact analysis revealed statistically significant reduction in implant loss rate (P < 0.00001) following protocol introduction.

CONCLUSIONS

Implant loss rate following IBR can be reduced to an exceptionally low level, well below national targets, by adhering to this evidence-based intervention bundle. Our protocol could improve outcomes nationally.

Multicentre study of prepectoral breast reconstruction using acellular dermal matrix

Background

Single‐stage reconstruction is used widely after mastectomy. Prepectoral implant placement is a relatively new technique. This multicentre audit examined surgical outcomes following prepectoral reconstruction using acellular dermal matrix (ADM).

Methods

All patients who had a mastectomy with prepectoral breast reconstruction and ADM in the participating centres between January 2015 and December 2017 were included. Demographic and treatment details, and short‐ and long‐term operative outcomes were recorded. Factors affecting complications and implant loss were analysed: age, BMI, smoking status, diabetes, vascular disease, laterality of surgery, previous ipsilateral breast surgery or radiotherapy, indication for surgery (invasive versus in situ carcinoma, or risk reduction), type of mastectomy, axillary clearance, breast volume, implant volume, and neoadjuvant and adjuvant chemotherapy.

Results

A total of 406 reconstructions were performed across 18 centres. Median follow‐up was 9·65 months. Median hospital stay was 1 day. The 90‐day unplanned readmission rate was 15·7 per cent, and the return‐to‐theatre rate 16·7 per cent. Some 15·3 per cent of patients had a major complication, with a 90‐day implant loss rate of 4·9 per cent. A further six patients had delayed implant loss. In multivariable analysis, no factor was significantly associated with complications or implant loss.

Conclusion

Prepectoral breast reconstruction with ADM has satisfactory surgical outcomes. The duration of follow‐up needs to be extended to examine outcomes in patients who received adjuvant radiotherapy.

Increasing Role of Oncoplastic Surgery for Breast Cancer

PURPOSE OF REVIEW

The goals of surgery for breast cancer have remained the same over the years, to eliminate breast cancer from the breast with the least degree of deformity. With the current expectation of long-term survival after breast cancer treatment, more attention has turned to the cosmetic result of the surgical treatment. Whether lumpectomy or mastectomy, the need for aesthetic improvement was recognized by surgeons both in and outside the USA.

RECENT FINDINGS

Oncoplastic surgery combines the skills of the cancer surgeon with those of the plastic surgeon. Sometimes, this means a team approach with a breast surgeon and a plastic surgeon both performing their mutual skills for the patient. Other times, the properly trained breast surgeon may perform some of the plastic techniques at the time of cancer surgery. Breast surgeons are rapidly gaining the ability to improve the post-cancer treatment appearance. To simplify the classification of oncoplastic techniques, we have used lower level, upper level, and highest level. The assignment of techniques to levels is based on both the technique and the surgeon's training and experience. Much data has accumulated demonstrating the safety and efficacy of the "aesthetic cancer cure." We describe the development of oncoplastic surgery, the techniques available, matching the right candidate with the right technique, and some comments about the future. It is clear from both clinical benefit and patient satisfaction that oncoplastic breast cancer procedures are here to stay. Plastic surgeons will likely focus on the upper- and highest-level procedures while breast/general surgeons will learn lower-level procedures and some of upper-level procedures as needed by their locale. Opportunities to educate breast/general surgeons in these techniques will continue to increase over the next several years. Formal education in oncoplastic surgery during breast fellowships will be necessary to catch up with the rest of the surgical world outside the USA.

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction

BACKGROUND

Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients.

METHODS

The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence.

RESULTS

The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69).

CONCLUSION

This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Acellular dermal matrices as an adjunct to implant breast reconstruction: Analysis of outcomes and complications

PURPOSE

Acellular dermal matrices (ADM) are increasingly used in implant-based breast reconstruction (IBR). Uncertainty remains with regard to their efficacy and complications. The aim of this study was to evaluate the outcomes and complication rates associated with the use of ADMs in IBR.

METHODS

Retrospective cohort study of patients undergoing ADM-assisted IBR between 2008 and 2013. Cases were identified from a prospectively collected database. Simple descriptive statistics and logistic regression analysis were performed.

RESULTS

A total of 110 patients (175 mastectomies) were included in the analysis. The median age was 46 (19-75) years and the median BMI was 22.2 (16.2-41.5). Seventy nine mastectomies were performed for therapeutic purposes. The median mastectomy weight was 244 (185-335) gr. The majority of reconstructions were performed with fixed volume (n = 115, 66%) or permanent expandable implants (n = 53, 30%) as one-stage procedures. Forty mastectomies were associated with at least one complication. The infection rate was 2.3% (n = 4). Post-operative haematoma developed in 5 cases (2.9%), but only 2 required surgical interventions. Three mastectomies were complicated by nipple necrosis (3.6%), 3 with skin necrosis (1.7%) and 9 with wound dehiscence (5.1%). The capsule formation rate was 2.3% (n = 4). Reconstruction failure with implant loss occurred in 3 cases (1.7%).

CONCLUSIONS

The complication rates following ADM-assisted IBR can be very low with appropriate patient selection and meticulous surgical technique. This supports the safety of using ADM in carefully selected patients. Further research is warranted to assess the health economics of ADM use in IBR.

Therapeutic Breast Reconstruction Using Gene Therapy-Delivered IFNγ Immunotherapy

After mastectomy, breast reconstruction is increasingly performed using autologous tissue with the aim of improving quality of life. During this procedure, autologous tissue is excised, relocated, and reattached using microvascular anastomoses at the site of the extirpated breast. The period during which the tissue is ex vivo may allow genetic modification without any systemic exposure to the vector. Could such access permit delivery of therapeutic agents using the tissue flap as a vehicle? Such delivery may be more targeted and oncologically efficient than systemic therapy, and avoid systemic complications. The cytokine IFNγ has antitumor effects, and systemic toxicity could be circumvented by localized delivery of the IFNγ gene via gene therapy to autologous tissue used for breast reconstruction, which then releases IFNγ and exerts antitumor effects. In a rat model of loco-regional recurrence (LRR) with MADB-106-Luc and MAD-MB-231-Luc breast cancer cells, autologous tissue was transduced ex vivo with an adeno-associated viral vector encoding IFNγ. The "Therapeutic Reconstruction" released IFNγ at the LRR site and eliminated cancer cells, significantly decreased tumor burden, and increased survival compared with sham reconstruction (P <0.05). Mechanistically, localized IFNγ immunotherapy stimulated M1 macrophages to target cancer cells within the regional confines of the modified tumor environment. This concept of "Therapeutic Breast Reconstruction" using ex vivo gene therapy of autologous tissue offers a new application for immunotherapy in breast cancer with a dual therapeutic effect of both reconstructing the ablative defect and delivering local adjuvant immunotherapy.