1
|
Zhong T, Fletcher GG, Brackstone M, Frank SG, Hanrahan R, Miragias V, Stevens C, Vesprini D, Vito A, Wright FC. Postmastectomy Breast Reconstruction in Patients with Non-Metastatic Breast Cancer: A Systematic Review. Curr Oncol 2025; 32:231. [PMID: 40277787 PMCID: PMC12025830 DOI: 10.3390/curroncol32040231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2025] [Revised: 04/09/2025] [Accepted: 04/11/2025] [Indexed: 04/26/2025] Open
Abstract
Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed-with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results.
Collapse
Affiliation(s)
- Toni Zhong
- Plastic and Reconstructive Surgery, University Health Network, Toronto, ON M5G 2C4, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada;
| | - Glenn G. Fletcher
- Program in Evidence-Based Care, Department of Oncology, McMaster University, Hamilton, ON L8V 5C2, Canada;
| | - Muriel Brackstone
- Department of Surgery, London Regional Cancer Program, London, ON N6A 5W9, Canada;
- Departments of Surgery and of Oncology, University of Western Ontario, London, ON N6A 5W9, Canada
| | - Simon G. Frank
- Department of Surgery, The Ottawa Hospital, Ottawa, ON K1H 8L6, Canada;
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, ON K1Y 4E9, Canada
| | - Renee Hanrahan
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada;
- Department of Surgery, Royal Victoria Regional Health Care Centre, Barrie, ON L4M 6M2, Canada
- Department of Surgery, McMaster University, Hamilton, ON L8S 1C7, Canada
| | | | - Christiaan Stevens
- Radiation Treatment Program, Royal Victoria Hospital, Barrie, ON L4M 6M2, Canada;
- Departments of Radiation Oncology and of Family and Community Medicine, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Danny Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Hospital, Toronto, ON M4N 3M5, Canada;
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Alyssa Vito
- Patient Representative, Port Perry, ON, Canada;
| | - Frances C. Wright
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada;
- Departments of Surgery and of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 1P5, Canada
- Surgical Oncology Program, Ontario Health (Cancer Care Ontario), Toronto, ON M5G 2L3, Canada
| |
Collapse
|
2
|
Bogdan RG, Helgiu A, Cimpean AM, Ichim C, Todor SB, Iliescu-Glaja M, Bodea IC, Crainiceanu ZP. Assessing Fat Grafting in Breast Surgery: A Narrative Review of Evaluation Techniques. J Clin Med 2024; 13:7209. [PMID: 39685668 DOI: 10.3390/jcm13237209] [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: 10/16/2024] [Revised: 11/19/2024] [Accepted: 11/25/2024] [Indexed: 12/18/2024] Open
Abstract
Fat grafting has gained prominence in reconstructive and aesthetic surgery, necessitating accurate assessment methods for evaluating graft volume retention. This paper reviews various techniques for assessing fat and fat grafts, including their benefits and limitations. Three-dimensional (3D) scanning offers highly accurate, non-invasive volumetric assessments with minimal interference from breathing patterns. Magnetic resonance imaging (MRI) is recognized as the gold standard, providing precise volumetric evaluations and sensitivity to complications like oil cysts and necrosis. Computed tomography (CT) is useful for fat volume assessment but may overestimate retention rates. Ultrasonography presents a reliable, non-invasive method for measuring subcutaneous fat thickness. Other methods, such as digital imaging, histological analysis, and weight estimation, contribute to fat graft quantification. The integration of these methodologies is essential for advancing fat graft assessment, promoting standardized practices, and improving patient outcomes in clinical settings.
Collapse
Affiliation(s)
- Razvan-George Bogdan
- Plastic Surgery Department, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- County Clinical Emergency Hospital Pius Branzeu, 300723 Timisoara, Romania
| | - Alina Helgiu
- Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550024 Sibiu, Romania
- County Clinical Emergency Hospital of Sibiu, 550245 Sibiu, Romania
| | - Anca-Maria Cimpean
- Plastic Surgery Department, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Cristian Ichim
- Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550024 Sibiu, Romania
| | - Samuel Bogdan Todor
- Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550024 Sibiu, Romania
| | - Mihai Iliescu-Glaja
- Plastic Surgery Department, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- County Clinical Emergency Hospital Pius Branzeu, 300723 Timisoara, Romania
| | - Ioan Catalin Bodea
- General Surgery Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology Prof. Dr. Octavian Fodor, 400394 Cluj-Napoca, Romania
| | - Zorin Petrisor Crainiceanu
- Plastic Surgery Department, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- County Clinical Emergency Hospital Pius Branzeu, 300723 Timisoara, Romania
| |
Collapse
|
3
|
Sowa Y, Nakayama I, Toyohara Y, Higai S, Yoshimura K. Pain-relieving Effects of Autologous Fat Grafting in Breast Cancer Surgery: A Scoping Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5909. [PMID: 38881960 PMCID: PMC11177809 DOI: 10.1097/gox.0000000000005909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/30/2024] [Indexed: 06/18/2024]
Abstract
Background Chronic pain is relatively common after breast cancer surgery, including breast reconstruction. Autologous fat grafting (AFG) has gained attention as a novel method for breast reconstruction, and recent clinical studies have also shown effects of AFG on alleviation of chronic pain after breast cancer surgery. Our objective was to conduct a scoping review of studies that have examined these effects with clearly defined clinical outcomes. Methods A literature search was conducted using three databases: PubMed, MEDLINE, and Google Scholar, following PRISMA guidelines and the Arkesy and O'Malley framework. The search focused on clinical studies of the effects of AFG on chronic pain after breast cancer surgery. All studies reporting functional outcomes, return to work, and secondary surgery in a repeat operation were identified. Results Of the 148 studies identified in the search, 11 studies with a total of 684 patients were included in the review. The average volume of fat grafted was approximately 128 mL over an average of 1.6 sessions. The most common time point for assessment was 1 year post-AFG. In all studies with an evidence level of 3 or lower, AFG showed positive results in alleviating pain after breast cancer surgery. However, one of the three randomized controlled trials did not show clinically significant effects. Conclusions Most of the studies examined in this review suggested pain-relieving effects of AFG. However, there was one randomized controlled trial in which these effects were not confirmed, indicating a need for further accumulation of cases and performance of new, well-designed randomized controlled trials.
Collapse
Affiliation(s)
- Yoshihiro Sowa
- From the Department of Plastic Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Ichiro Nakayama
- Department of Breast Surgery, Kyoto Miniren Chuo Hospital, Kyoto, Japan
| | - Yoshihiro Toyohara
- From the Department of Plastic Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Shino Higai
- From the Department of Plastic Surgery, Jichi Medical University, Shimotsuke City, Japan
| | - Kotaro Yoshimura
- From the Department of Plastic Surgery, Jichi Medical University, Shimotsuke City, Japan
| |
Collapse
|
4
|
Hansson E, Larsson C, Uusimäki A, Svensson K, Widmark Jensen E, Paganini A. A systematic review of randomised controlled trials in breast reconstruction. J Plast Surg Hand Surg 2024; 59:53-64. [PMID: 38751090 DOI: 10.2340/jphs.v59.40087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field. METHODS Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done. RESULTS A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction. CONCLUSIONS A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.
Collapse
Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Camilla Larsson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Alexandra Uusimäki
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Karolina Svensson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Emmelie Widmark Jensen
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden; Department of Diagnostics, Acute and Critical Care, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
5
|
Wolter A, Fertsch S, Lisboa BW, Andree C. [Breast Reconstruction Strategies in Case of Planned Radiotherapy]. HANDCHIR MIKROCHIR P 2022; 54:279-296. [PMID: 35728602 DOI: 10.1055/a-1826-2992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed. METHODS The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised. RESULTS An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients. CONCLUSION Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.
Collapse
Affiliation(s)
- Andreas Wolter
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany
| | - Sonia Fertsch
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany
| | | | - Christoph Andree
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany
| |
Collapse
|
6
|
Weinzierl A, Schmauss D, Brucato D, Harder Y. Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind? J Clin Med 2022; 11:jcm11113079. [PMID: 35683465 PMCID: PMC9181810 DOI: 10.3390/jcm11113079] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 01/15/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Andrea Weinzierl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Germany;
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
| |
Collapse
|