Options in Reconstructing the Irradiated Breast:

Color differences of skin paddles using the free flap for autologous breast reconstruction in Asian patients

BACKGROUND

In this study, we aimed to evaluate color differences of the skin paddle in autologous breast reconstruction performed using the deep inferior epigastric artery perforator (DIEP) flap and the profunda artery perforator (PAP) flap. The primary focus was to compare the color match between the reconstructed breast skin and the donor-site skin, to achieve optimal esthetic results.

METHODS

A retrospective analysis was performed on patients who had undergone unilateral breast reconstruction with a DIEP flap or a PAP flap between January 2020 and December 2022. The colors were captured using a digital camera and analyzed using Adobe Photoshop 2024 software. The L*, a*, and b* coordinates were used. The International Commission on Illumination Delta E 2000 (CIEDE2000) score was used to quantify color differences, comparing skin tones of the unaffected breast, DIEP flap, PAP flap, abdomen, and medial thigh.

RESULTS

A total of 125 patients were analyzed. The DIEP flap demonstrated a closer color match to the native breast skin compared with the PAP flap (CIEDE2000 scores, 5.29 vs. 8.69, p < 0.01). No significant difference in color deformity with time was found between the DIEP flap and the PAP flap (CIEDE2000 scores, 5.61 vs. 8.25, p = 0.17).

CONCLUSION

Our findings suggest that the DIEP flap results in a more favorable color match for breast reconstruction than the PAP flap, enhancing esthetic outcomes. These results underscore the importance of considering skin color matching in flap selection for breast reconstruction surgery.

Impact of the Prepectoral Breast Reconstruction Assessment Score on Expander-Based Reconstruction Success

Background/Objectives: The rising incidence of breast cancer has led to more mastectomies and increased demand for reconstruction. While retropectoral reconstruction with expanders is common, it has complications like postoperative pain and animation deformity. Prepectoral reconstruction, aided by advancements in biological and synthetic meshes, offers a promising alternative. Methods: This study prospectively evaluated the "Prepectoral Breast Reconstruction Assessment Score" on 20 patients undergoing mastectomy at Policlinico Umberto I, Rome, from July 2022 to February 2024. Patients with scores between 5 and 8 were included. The procedure involved the use of ADM (Acellular Dermal Matrix) or titanium-coated polypropylene mesh, followed by postoperative expansions and final implant placement after six months. Results: The mean age of patients was 51.85 years, with a mean BMI of 24.145 kg/m2. ADM was used in 15 cases and synthetic mesh in 5. Complications were one exposure of the expander, one superficial skin necrosis and one seroma. Statistical analysis showed a trend toward fewer complications with higher scores, though this was not statistically significant (p-value = 0.139). Conclusions: Prepectoral reconstruction with expanders is a viable option, offering benefits such as reduced operating time, better volume control, and a more natural breast contour compared to the retropectoral approach. Although the trend suggests fewer complications with higher assessment scores, further studies with larger samples are needed for confirmation.

Impact of Neoadjuvant Chemotherapy and Preoperative Irradiation on Early Complications in Direct-to-Implant Breast Reconstruction

Background  Impact of previous radiation therapy and neoadjuvant chemotherapy (NACT) on early complications in direct-to-implant (DTI) breast reconstruction has not been elucidated. This study investigated whether DTI reconstruction is viable in patients with NACT or a history of preoperative chest wall irradiation. Methods  Medical records of breast cancer patients who underwent nipple-sparing or skin-sparing mastectomy with DTI breast reconstruction from March 2018 to February 2021, with at least 1 year of follow-up in a single tertiary center, were reviewed. Demographic data, intraoperative details, and postoperative complications, including full-thickness necrosis, infection, and removal, were reviewed. Risk factors suggested by previous literature, including NACT and preoperative chest wall irradiation histories, were reviewed by multivariate analysis. Results  A total of 206 breast cancer patients were included, of which, 9 were bilateral, 8 patients (3.9%) had a history of prior chest wall irradiation, and 17 (8.6%) received NACT. From 215 cases, 11 cases (5.1%) required surgical intervention for full-thickness necrosis, while intravenous antibiotics or hospitalization was needed in 11 cases (5.1%), with 14 cases of failure (6.5%) reported. Using multivariable analysis, preoperative irradiation was found to significantly increase the risk of full-thickness skin necrosis (OR = 12.14, p  = 0.034), and reconstruction failure (OR = 13.14, p  = 0.005). NACT was not a significant risk factor in any of the above complications. Conclusion  DTI breast reconstruction is a viable option for patients who have received NACT, although reconstructive options should be carefully explored for patients with a history of breast irradiation.

Surgical Outcomes of Implant versus Autologous Breast Reconstruction in Patients with Previous Breast-Conserving Surgery and Radiotherapy

BACKGROUND

Postmastectomy breast reconstruction in patients with a history of breast-conserving surgery (BCS) and radiotherapy is challenging, with a paucity of literature on the outcomes of different breast reconstructive techniques. The authors hypothesized that implant-based breast reconstruction (IBR) would be associated with higher complication rates compared to either IBR combined with latissimus dorsi (LD) or free flap breast reconstruction (FFBR).

METHODS

The authors conducted a retrospective review of patients who underwent mastectomy with a history of BCS and radiotherapy between January of 2000 and March of 2016. Surgical and patient-reported outcomes (BREAST-Q) were compared between IBR versus IBR/LD versus FFBR.

RESULTS

The authors identified 9473 patients who underwent BCS and radiotherapy. Ninety-nine patients (105 reconstructions) met the authors' inclusion criteria, 29% ( n = 30) of whom underwent IBR, 26% ( n = 27) of whom underwent IBR/LD, and 46% ( n = 48) of whom underwent FFBR. The overall complication rate was not significantly different between the three groups (50% in IBR versus 41% in IBR/LD versus 44% in FFBR; P = 0.77), whereas reconstruction failures were significantly lower in the FFBR group (33% in IBR versus 19% in IBR/LD versus 0% in FFBR; P < 0.0001). The time between the receipt of radiotherapy and reconstruction was not a significant predictor of overall complications and reconstruction failure. No significant differences were identified between the three study cohorts in any of the three studied BREAST-Q domains.

CONCLUSIONS

In patients with prior BCS and radiotherapy, FFBR was associated with lower probability of reconstruction failure compared to IBR but no significant difference in overall and major complication rates. The addition of LD flap to IBR did not translate into lower complication rates but may result in decreased reconstruction failures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Conversion of Breast Implants into Natural Breast Reconstruction: Evaluating Lipofilled Mini Dorsi Flap

Background:

Autologous reconstruction techniques can provide a long-lasting natural breast reconstruction for patients. This study aimed to further investigate outcomes in the conversion of breast implant reconstruction into a lipofilled mini dorsi flap, focusing on reviewing its techniques, efficiency, and final results.

Methods:

Over 3 years, we performed a number of breast implant replacements via the lipofilled mini dorsi flap technique. The artificial implants were replaced to a deepithelized flap. The efficiency and tolerance of the technique were evaluated by the whole surgical team, and the achieved results were also analyzed by the patients in terms of postoperative pain, functional impact, and the softness of the reconstructed breast by comparing their prior condition to the lipofilled mini dorsi flap condition at least 9 months after operation.

Results:

Forty-seven consecutive operations were prospectively studied. The mean ± standard deviation volume of the removed implants was 348.66 ± 86.54 mL. The mean volume of fat injected was 284.13 ± 62.94 mL. The procedure’s average duration was 108.93 ± 17.65 minutes. The surgical team evaluated the results as very satisfactory in 32 cases (68.1%), satisfactory in 15 cases (31.9%), and moderately satisfactory or unsatisfactory in zero cases (0.0%). Eighteen patients (38.3%) evaluated their reconstruction as very good, while 20 patients (42.6%) considered their reconstruction as good, four (8.5%) as average, and zero (0.0%) as insufficient.

Conclusion:

According to our experience, the lipofilled mini dorsi flap is a simple, less invasive, and quick procedure to convert breast implants into natural breast reconstruction.

Mastectomy options for the treatment of ipsilateral breast cancer recurrence after lumpectomy

BACKGROUND

Mastectomy is the recommended treatment for ipsilateral breast tumor recurrence (IBTR) in patients who initially received breast conservation surgery (BCS) and radiation. We evaluated the 3 types of mastectomies performed for the surgical treatment of IBTR (nipple sparing (NSM), skin sparing (SSM) and total mastectomy (TM)) to assess surgical complications and local control outcomes among groups.

METHODS

Patients who developed IBTR after BCS and received mastectomy from 2011 to 2019 were reviewed. Patient characteristics and treatment were analyzed. The incidence of postoperative complications and second breast cancer recurrence were compared.

RESULTS

Mastectomy was performed in 113 patients presenting with isolated IBTR (17 NSM, 48 SSM and 48 TM). There was no difference in post-operative complications between groups. At 3-year follow-up, 5 (4%) patients had a second recurrence. Tumor size at IBTR was the only predictor for second recurrence and not mastectomy type or receipt of reconstruction.

CONCLUSION

In patients initially treated with BCS who experienced an IBTR, NSM or SSM mastectomy with immediate reconstruction had low complication rates and no increase in local recurrence compared to the TM group.

Combined skin-sparing mastectomy and immediate implant-based breast reconstruction: Outcome following mantle field irradiation versus outcome following whole-breast irradiation

BACKGROUND

Mastectomy may be needed in the context of previous radiotherapy in cases of breast carcinoma following mantle field radiotherapy for Hodgkin lymphoma or in cases of local relapse or second primary tumours after breast conserving therapy including whole-breast irradiation (BCT). The outcome of combined skin-sparing mastectomy and immediate implant-based breast reconstruction (SSM-IIBR) has been reported to be unfavourable in these cases.

PURPOSE

To compare the outcome of SSM-IIBR after mantle field radiotherapy to that after BCT and to compare both to the outcome observed in non-irradiated breasts.

METHODOLOGY

The prevalences of short-term events, device loss, long-term corrections and secondary reconstructions, and reversion to autologous tissue techniques of 42 SSM-IIBRs performed after mantle field irradiation were compared to those of 47 salvage SSM-IIBRs following BCT. Both outcomes were compared to the outcome in the contralateral, non-irradiated breast of the subgroup of 23 women in the BCT group.

RESULTS

The groups were comparable in terms of patient- and procedure-related risk factors, except for time lapse after previous therapy, intraoperative device weight, and the fraction of immediate use of a definitive implant. The outcome of SSM-IIBR after mantle field irradiation significantly differs favourably from that after BCT. It matches the outcome observed in non-irradiated breasts.

CONCLUSION

Skin-sparing mastectomy combined with immediate implant-based breast reconstruction is a fully justifiable option for women who previously underwent mantle field irradiation for Hodgkin lymphoma. We feel that the unfavourable outcome observed in women who previously underwent BCT necessitates an alternative reconstructive modality.

"To Pre or Not to Pre": Introduction of a Prepectoral Breast Reconstruction Assessment Score to Help Surgeons Solving the Decision-Making Dilemma. Retrospective Results of a Multicenter Experience

BACKGROUND

Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction.

METHODS

Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed.

RESULTS

Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement.

CONCLUSIONS

To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient's risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of Immediate Implant-Based Mastectomy Reconstruction in Women with Previous Breast Radiotherapy

BACKGROUND

The objective of this study was to determine whether women with a history of radiation therapy before mastectomy experience a risk for postoperative complications and patient-reported outcomes similar to those of women undergoing postmastectomy radiation therapy in the setting of immediate implant reconstruction.

METHODS

The cohort included patients undergoing immediate implant reconstruction at 11 centers across North America. Women were categorized into three groups: prior breast conservation therapy, postmastectomy radiation therapy, and no radiation therapy. Mixed effect logistic regressions were used to analyze the effects of radiation therapy status on complication rates and patient-reported outcomes.

RESULTS

ONE THOUSAND FIVE HUNDRED NINETY-FOUR: patients were analyzed, including 84 women with prior breast conservation therapy, 329 women who underwent postmastectomy radiation therapy, and 1181 women with no history of radiation therapy. Compared with postmastectomy radiation therapy, breast conservation was associated with lower rates of all complications and major complications (OR, 0.65; 95 percent CI, 0.37 to 1.14; p = 0.13; and OR, 0.61; 95 percent CI, 0.33 to 1.13; p = 0.12). These differences were not statistically significant. Rates of reconstructive failure between the two cohorts were comparable. Before reconstruction, satisfaction with breasts was lowest for women with prior breast conservation therapy (p < 0.001). At 2 years postoperatively, satisfaction with breasts was lower for women with postmastectomy radiation therapy compared with breast conservation patients (p = 0.007).

CONCLUSIONS

Higher postoperative complication rates were observed in women exposed to radiation therapy regardless of timing. Although women with prior breast conservation experienced greater satisfaction with their breasts and fewer complications when compared to women undergoing postmastectomy radiation therapy, there was a similar risk for reconstruction failure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Immediate Latissimus Dorsi and Prosthetic Reconstruction in the Setting of Postmastectomy Radiation: An Analysis of 376 Breast Reconstructions

BACKGROUND

In immediate breast reconstruction, the plastic surgeon must strive to create an aesthetically pleasing result while minimizing complications. The latissimus dorsi (LD) myocutaneous flap has long been used a workhorse flap in breast reconstruction. Often times, it is used a salvage flap after other methods of breast reconstruction have failed. In this study, we review the use of this flap in conjunction with prosthetic devices, regardless of the need for adjuvant radiation, to determine the safety and efficacy of this approach as a primary method of reconstruction.

METHODS

A single surgeon practice with a standardized reconstructive algorithm was reviewed. This compromises a 2-stage approach involving the use of LD myocutaneous flaps and tissue expanders for immediate reconstruction after mastectomy, followed by exchange for implants at a secondary surgery. A retrospective chart review was performed on 201 patients (376 breast reconstructions) who met inclusion criteria. Patient demographics and outcomes were compared based on radiation status. The primary outcome, reconstructive success, was defined as no need for further autologous reconstruction beyond the 2-stage approach utilized.

RESULTS

Statistical analysis was performed on both patient demographics, complications, and reconstructive outcomes. Demographics were equivalent between the 2 groups. When analyzing complications and outcomes, there was no difference between nonradiated patients and radiated patients except when looking at reconstructive loss, which was 3.6% in the nonradiated group and 16.6% in the radiated group (P = 0.03). However, one third of the patients in the radiated group who had reconstructive losses were due to reasons not related to radiation therapy. Taking this into account, overall reconstructive success showed no statistical significance between the 2 groups.

CONCLUSIONS

The findings from this study show that immediate reconstruction with LD myocutaneous flaps in conjunction with prosthetic devices is a reliable and safe option, even in the setting of adjuvant radiation therapy, as the autologous tissue mitigates many sequelae of radiation therapy. Not only does this type of reconstruction provide an aesthetically pleasing result in 2 stages, but also has a favorable complication profile and success rate.

Lipofilled Mini Dorsi Flap: An Efficient Less Invasive Concept for Immediate Breast Reconstruction

INTRODUCTION

The traditional extended latissimus dorsi flap technique, in addition to lipofilling, has been one of the main procedures used for breast reconstruction after mastectomy. However, to obtain excellent results, this technique requires a large muscle harvest and further lipofilling sessions. The lipofilled mini dorsi flap technique, performed in a single operation, appealed to us as a way to improve the traditional technique.We present our experience with the lipofilled mini dorsi flap technique in a new scenario.

MATERIALS AND METHODS

We performed breast reconstruction with a lipofilled mini dorsi flap in female patients with breast cancer who underwent mastectomy and immediate breast reconstruction with a lipofilled mini dorsi flap. The operative technique is detailed in this article. The results were evaluated by the patients and the surgical team.

RESULTS

We performed 72 lipofilled mini dorsi flap procedures during breast reconstruction surgery from May 2017 to January 2019. Fifty-nine (81.9%) cases were immediate reconstructions. Complications, such as infection or necrosis of the flap, were not observed in this study. We noticed seroma and 1 case of infected lymphocele, which was drained.Body mass index (BMI) was directly related to postoperative dorsal seroma. The authors reported that greater BMI was associated with a higher seroma volume.Most patients evaluated their reconstruction as satisfactory. The surgical team evaluated most of the results as very satisfactory or satisfactory. There were no cases of unsatisfactory results reported either by the patients or the surgical team.

CONCLUSIONS

The lipofilled mini dorsi flap technique is an efficient, elegant, and less invasive solution that is more easily and quickly performed and achieves excellent long-term results in the immediate breast reconstruction scenario. For the first time to our knowledge, lipofilling was used to reduce the extent of latissimus dorsi dissection. The postoperative follow-up was better tolerated by patients. This technique may be offered to patients regardless of oncological treatment. In our experience, the lipofilled mini dorsi flap method has become the primary technique for immediate breast reconstruction.

Prepectoral breast reconstruction

Implant-based breast reconstruction is the most commonly used reconstruction technique after mastectomy. This is because skin-sparing mastectomy has become possible with advancements in oncology. In addition, the development of breast implants and the advent of acellular dermal matrices have reduced postoperative complications and resulted in superior cosmetic results. The most frequently performed surgical breast reconstruction procedure for the past 20 years was the insertion of an implant under the pectoralis major muscle by means of the dual plane approach. However, some patients suffered from pain and animation deformity caused by muscle manipulation. Recently, a prepectoral approach has been used to solve the above problems in select patients, and the results are similar to subpectoral results. However, this technique is not always chosen due to the number of considerations for successful surgery. In this article, we will discuss the emergence of prepectoral breast reconstruction, indications and contraindications, surgical procedures, and outcomes.

Immediate and Long-term Complications of Direct-to-implant Breast Reconstruction after Nipple- or Skin-sparing Mastectomy

Background:

Traditionally, breast reconstruction options after mastectomy comprise an autologous flap or staged expander/implant reconstruction, or a combination of both. Recent introduction of skin or nipple-sparing mastectomies have led to much interest in direct-to-implant immediate breast reconstructions. We performed a retrospective review of our initial experience.

Methods:

Between June 1998 and December 2010, 31 of 671 patients (4.6%) who received implant-only breast reconstruction underwent direct-to-implant immediate breast reconstruction after mastectomy for primary or recurrent cancers, or risk reduction. Their files were audited, and the primary factor examined was the failure of reconstruction with loss of prosthesis. Other complications, revision surgery, and aesthetic result are also recorded.

Results:

The mean follow-up period for the 31 patients was 49.5 months. A total of 45 mastectomies were performed for 21 primary and 4 recurrent breast cancers after previous conservation surgery and radiotherapy (RT), and 20 for risk reduction. Ten patients received RT (4 before mastectomy and 6 afterward). Average size of implants was 380.0 g (range, 205–620 g). The most common postoperative complications were seromas (20%); only 1 implant was lost (2.22%). Nineteen breasts required revision surgery after 6 months with 1 more implant lost. Despite the high revision rate, 28 (90.3%) had excellent or good aesthetic result.

Conclusions:

Immediate single-stage direct-to-implant breast reconstruction has a high rate of both immediate postoperative complications and revisions after 6 months, especially after RT. However, most complications are manageable and do not necessarily result in implant loss. Most cases can have a successful outcome without implant loss with excellent or good cosmetic results.

Capsular fibrosis in aesthetic and reconstructive-cancer patients: A retrospective analysis of 319 cases

BACKGROUND

Implant-based breast augmentation is one of the most frequently performed operations in plastic surgery worldwide, for aesthetic and reconstructive reasons. Capsular fibrosis is the most common long-term foreign body response after breast implant augmentation.

OBJECTIVE

To compare the occurrence of capsular contracture in aesthetic and reconstructive-cancer patients, including those patients who received radiotherapy prior to breast reconstruction with implants.

METHODS

We conducted a retrospective evaluation of 319 patients who underwent breast implant revision between Jan 2000 and Oct 2016. The patient group was comprised of 175 reconstructive-cancer patients and 144 patients who underwent operation for aesthetic reasons. The occurrence of capsular fibrosis, other complications and the time-period between implantation of breast implants and revision surgery (TP) was analyzed.

RESULTS

For all 319 patients the mean TP was 7.9 years (7.86±0.45). The most common complication in all revisions was capsular fibrosis (65.1% of all revisions). In aesthetic patients with capsular fibrosis the mean TP was 11.9 years (11.89±0.95, p < 0.001). This mean TP was significantly higher than the mean TP of 6.1 years (6.13±0.56, p < 0.001) in breast cancer patients with capsular fibrosis. Preoperatively irradiated cancer patients had a mean TP of 6.2 years (6.17±0.95), compared to a mean TP of 5.1 years (5.07±0.19, p = 0.051) in non-irradiated cancer patients, which was not significantly different.

CONCLUSIONS

We found that aesthetic patients exhibit a significantly higher mean TP compared to breast cancer patients, suggesting that reconstructive-cancer patients in general develop capsular fibrosis earlier. Despite the literature, we did not find a significant influence of preoperative radiotherapy on the occurrence of capsular fibrosis in reconstructive-cancer patients. Further clinical studies need to be conducted to identify methods to decrease the risk of developing capsular fibrosis.

Timing of radiation therapy in nipple-sparing mastectomy influences outcomes and patient-reported quality of life

The aim of this study is to assess the complication profile and impact on patient-reported quality of life in those undergoing nipple-sparing mastectomy (NSM) with immediate breast reconstruction and subsequent prosthetic reconstruction in patients with prior breast radiation therapy (pRT) vs those receiving adjuvant post-mastectomy radiation therapy (PMRT). An IRB-approved, retrospective analysis was performed from 2002 to 2014 to identify NSM patients that underwent pRT or PMRT. A 22-item Likert scale questionnaire was administered by a third party to register patient-reported quality of life. Forty patients met criteria for outcomes analysis, and 30 patients answered the questionnaire. Mean age was 45.6 years old and mean follow-up was 3.8 years. Complication rates for the PMRT cohort were 61.9% vs 31.6% in the pRT cohort, P = .067, and those requiring operative intervention were PMRT 38.1% vs pRT 5.3%, P = .021. Nipple-areolar complex survival was 100% in the pRT vs 85.7% in the PMRT, P = .233. Breast-related quality of life scores were superior in the pRT group within multiple domains. Patients are more likely to develop complications requiring an operative intervention and have decreased breast-related quality of life when undergoing NSM with PMRT compared to patients undergoing NSM having received pRT.

Important Considerations for Performing Prepectoral Breast Reconstruction

Prepectoral breast reconstruction has emerged as an excellent technique for postmastectomy reconstruction, as it allows for full preservation of a patient's pectoralis major muscle and chest wall function. This reduces pain, eliminates animation deformity, and results in high patient satisfaction. Safely performed prepectoral breast reconstruction requires a careful patient selection process before committing to the procedure, taking into account comorbidities, radiation status, and oncologic criteria such as tumor location and breast cancer stage. Furthermore, a thorough intraoperative assessment of mastectomy skin flaps is critical, with careful and precise confirmation that the skin is viable and well perfused, prior to proceeding with prepectoral breast reconstruction. This can be done both clinically and with perfusion assessment devices. The use of acellular dermal matrix (ADM) has enhanced outcomes and aesthetics of prepectoral reconstruction, by providing implant coverage and soft-tissue support. The ADM also adds the benefit of reducing capsular contracture rates and offers full control over the aesthetic definition of the newly reconstructed breast pocket. Aesthetic enhancement of results requires routine use of oversizing implants in the skin envelope, careful selection of full capacity or cohesive gel implants, and autologous fat grafting. In this way, patients in all clinical scenarios can benefit from the full muscle-sparing technique of prepectoral breast reconstruction, including those undergoing immediate reconstruction, delayed reconstruction, and delayed conversion from a subpectoral to prepectoral plane to correct animation deformity.

Two-Stage Prosthetic Breast Reconstruction after Mastectomy with or without Prior Postmastectomy Radiotherapy

BACKGROUND

Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period.

METHODS

Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded.

RESULTS

Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections.

CONCLUSIONS

Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.

Long-term outcome of adipose-derived regenerative cell-enriched autologous fat transplantation for reconstruction after breast-conserving surgery for Japanese women with breast cancer

PURPOSE

More effective methods are needed for breast reconstruction after breast-conserving surgery for breast cancer. The aim of this clinical study was to assess the perioperative and long-term outcomes of adipose-derived regenerative cell (ADRC)-enriched autologous fat grafting.

METHODS

Ten female patients who had undergone breast-conserving surgery and adjuvant radiotherapy for breast cancer were enrolled. An ADRC-enriched fat graft prepared from the patient's adipose tissue was implanted at the time of adipose tissue harvest. The perioperative and long-term outcomes of the grafts, which included safety, efficacy, and questionnaire-based patient satisfaction, were investigated.

RESULTS

The mean operation time was 188 ± 30 min, and the mean duration of postoperative hospitalization was 1.2 ± 0.4 days. No serious postoperative complications were associated with the procedure. Neither recurrence nor metastatic disease was observed during the follow-up period (7.8 ± 1.5 years) after transplantation. Of 9 available patients, "more than or equal to average" satisfaction with breast appearance and overall satisfaction were reported by 6 (66.7%) and 5 (55.6%) patients, respectively.

CONCLUSIONS

ADRC-enriched autologous fat transplantation is thus considered to be safe perioperatively, with no long-term recurrence, for patients with breast cancer treated by breast-conserving surgery, and it may be an option for breast reconstruction, even after adjuvant radiotherapy.

Immediate breast reconstruction following mastectomy in pregnant women with breast cancer

BACKGROUND

Surgical management of breast cancer in pregnancy (BCP) requires balancing benefits of therapy with potential risks to the developing fetus. Minimal data describe outcomes after mastectomy with immediate breast reconstruction (IR) in pregnant patients.

METHODS

Retrospective review was performed of patients who underwent IR after mastectomy within a BCP cohort. Parameters included intra- and post-operative complications, short-term maternal/fetal outcomes, surgery duration, and delayed reconstruction in non-IR cohort.

RESULTS

Of 82 patients with BCP, 29 (35%) had mastectomy during pregnancy: 10 (34%) had IR, 19(66%) did not. All IR utilized tissue expander (TE) placement. Mean gestational age (GA) at IR was 16.2 weeks. Mean surgery duration was 198 min with IR versus 157 min without IR. Those with IR delivered at, or close to, term infants of normal birthweight. No fetal or major obstetrical complications were seen. Post-mastectomy radiation (PMRT) was provided after pregnancy in 2 (20%) patients in the IR cohort and 12 (63%) in the non-IR cohort. All patients in the IR cohort successfully transitioned to permanent implant.

CONCLUSIONS

This report represents one of the largest series describing IR during BCP. IR after mastectomy increased surgery duration, but was not associated with adverse obstetrical or fetal outcomes. IR with TE may preserve reconstructive options when PMRT is indicated. J. Surg. Oncol. 2016;114:140-143. © 2016 Wiley Periodicals, Inc.

Optimal approach in early breast cancer: Radiation therapy

Radiation therapy significantly reduces by at least 70% the relative risk of local and regional recurrences for breast cancer after surgery. A positive influence on overall survival has been clearly demonstrated, especially for patients with a high absolute risk for locoregional recurrences. However, this is partially counterbalanced by late toxicity (dependent upon the radiation dose) especially to cardiac structures. Apart from this toxicity, a clear influence of radiation-therapy-related factors on functional and cosmetic outcome has also been demonstrated. Over time, technical improvements have led to a marked reduction in dose to the neighbouring organs, with a consequent drop in acute and late toxicity. This has also allowed the introduction of shorter radiation schedules, lowering the burden of treatment to the patient and the hospital. Several tools, techniques and guidelines have been developed to optimise the balance between the desired reduction in recurrence rates and side effects.

The multidisciplinary team should discuss all available treatment options for every individual breast cancer patient. Individualisation of the selection of the optimal combination of treatments, depending on patient and tumour-related factors, is of utmost importance. Apart from direct tumour-related outcomes, cosmesis and potential side effects have to be taken into account. Counselling should include known risk factors for survival and complications, including comorbidity.

MRI evaluation of post-mastectomy irradiated breast implants: prevalence and analysis of complications

AIM

To evaluate the effect of post-mastectomy radiation therapy (RT) on breast implants as detected by magnetic resonance imaging (MRI) searching for short-term complications.

MATERIALS AND METHODS

One hundred and forty patients (total of 144 implants) were evaluated by MRI; 80 (group 1) had undergone RT, whereas the remaining 60 patients (group 2) underwent mastectomy with implant reconstruction without RT. Two radiologists evaluated MRI images searching for implant rupture signs, sub-capsular seromas, capsular contracture, soft-tissue oedema, peri-implant fluid collections. Implant ruptures were classified as severe complications; seromas and capsular contractures as moderate complications; oedema and fluid collections as mild complications. The prevalence of MRI findings in the two groups was calculated and compared by unpaired t-test. Cohen's kappa statistics was used to assess interobserver agreement.

RESULTS

Sixty-nine out of 144 (48%) implants presented pathological findings at MRI with complication rates of 47.5 and 48.4 for groups 1 and 2, respectively. Two (5%) severe complications, 10 (26%) moderate complications, and 26 (69%) mild complications occurred in group 1 and surgical treatment was performed in 10 cases. Two (6%) severe complications, seven (23%) moderate complications, and 22 (71%) mild complications occurred in group 2 and surgical treatment was performed in eight cases. No significant difference between the two groups was found (p>0.1). Almost perfect agreement between the two radiologists was found for MRI image detection (k=0.86).

CONCLUSION

RT does not seem to cause a significant effect on breast implants in terms of complication rate in patients undergoing implant-based breast reconstruction. One-stage immediate implant-based breast reconstruction performed at the same time as mastectomy could be proposed.

Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis

BACKGROUND

The purpose of this study was to assess the cost-effectiveness of five standardized procedures for breast reconstruction to delineate the best reconstructive approach in postmastectomy patients in the settings of nonirradiated and irradiated chest walls.

METHODS

A decision tree was used to model five breast reconstruction procedures from the provider perspective to evaluate cost-effectiveness. Procedures included autologous flaps with pedicled tissue, autologous flaps with free tissue, latissimus dorsi flaps with breast implants, expanders with implant exchange, and immediate implant placement. All methods were compared with a "do-nothing" alternative. Data for model parameters were collected through a systematic review, and patient health utilities were calculated from an ad hoc survey of reconstructive surgeons. Results were measured in cost (2011 U.S. dollars) per quality-adjusted life-year. Univariate sensitivity analyses and Bayesian multivariate probabilistic sensitivity analysis were conducted.

RESULTS

Pedicled autologous tissue and free autologous tissue reconstruction were cost-effective compared with the do-nothing alternative. Pedicled autologous tissue was the slightly more cost-effective of the two. The other procedures were not found to be cost-effective. The results were robust to a number of sensitivity analyses, although the margin between pedicled and free autologous tissue reconstruction is small and affected by some parameter values.

CONCLUSIONS

Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.

Patient-centred decision making in breast reconstruction utilising the delayed-immediate algorithm

Delayed-immediate reconstruction is an increasingly valuable algorithm for patients anticipating post-mastectomy radiation therapy. Despite the cosmetic and long-term advantages of autologous tissue repair, a subset of patients choose implant-based reconstruction after their initial preference for autologous reconstruction. A critical evaluation of patients who initially planned to undergo delayed-immediate reconstruction but later chose to continue with implant-based reconstruction has not been previously reported. A retrospective analysis of the senior author's (M.Y.N.) patients who initially intended to undergo delayed-immediate autologous breast reconstruction following mastectomy and chose to abandon autologous reconstruction in favour of prosthetic reconstruction was completed from 2005 to 2011. Seven patients (10 breasts) met inclusion criteria. The mean patient age and body mass index were 50.2 years and 32.1 kg m(-2), respectively. Expansion required an average of 4.4 office visits to achieve adequate expansion volume, mean 483 ml (240-600 ml). The mean time from expander placement to definitive reconstruction was 14.6 months. Mean follow-up time was 20.4 months. Complications included infection (1/7), incisional dehiscence (1/7) and capsular contracture (2/7), and late revision surgery was performed in two patients. Successful reconstruction was achieved in 100% of patients (7/7) with a patient-reported satisfaction of 100%. Patient motivations for changing the reconstructive algorithm included a faster post-operative recovery in four patients (4/7) and potential donor-site morbidity in three patients (3/7). Depression or cancer-related fatigue symptoms were self-reported in 4/7. Avoiding donor-site morbidity and a simpler recovery are the main factors that influence patients to change their desire for autologous reconstruction to an implant-based reconstruction. Cancer-related fatigue and depression are prevalent in this population and may be implicated in a patient's desire to undergo less extensive reconstructive surgery. Allowing for the choice of definitive implant-based reconstruction in select patients is safe and is likely to result in high patient satisfaction with satisfactory aesthetic outcomes.

Treatment of irradiated expanders: protective lipofilling allows immediate prosthetic breast reconstruction in the setting of postoperative radiotherapy

BACKGROUND

Immediate two-stage prosthetic breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) currently is hardly achieved with the fast-track expander exchange proposed by Cordeiro and colleagues or the delayed-immediate breast reconstruction proposed by Kronowitz and Robb. Each of these techniques has important drawbacks and complications. To overcome these problems, the authors in 2011 described lipofilling on irradiated expanders in patients undergoing unplanned PMRT (Cagliari University Hospital [CUH] protocol) for early breast cancers with specific risk factors. The authors report their experience after expanding the use of such a protocol for any immediate expander/implant reconstruction in a patient undergoing PMRT.

METHODS

The timing for advanced breast cancer involves immediate reconstruction with a tissue expander, complete tissue expansion, radiotherapy (RT) after neoadjuvant chemotherapy starting 2-3 months after mastectomy, one or two fresh fat-grafting sessions at least 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. The timing for early breast cancers with specific risk factors involves immediate reconstruction with a tissue expander, complete tissue expansion during postoperative chemotherapy, RT 6 months after mastectomy, one or two fat-grafting sessions 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. From 2008 to 2012, 16 patients undergoing total mastectomy and immediate expander-implant breast reconstruction with subsequent PMRT were treated according to the CUH protocol.

RESULTS

The results have been extremely encouraging, with rates of ulceration and implant exposure in the radiotreated area dropping to 0 %. These results were retrospectively compared with those for a control group of 16 patients who underwent immediate implantation of an expander. In this latter group, the extrusion rate of the implant in the end was 31.25 %, and this was statistically significant (p < 0.03). The shape and symmetry also were significantly better in the lipofilled patients.

CONCLUSION

Protective lipofilling on irradiated expanders appears to be a valid technique for avoiding ulceration and implant exposure after PMRT while allowing a complete expansion.

LEVEL OF EVIDENCE IV

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A systematic review of complications of implant-based breast reconstruction with prereconstruction and postreconstruction radiotherapy

PURPOSE

To conduct a systematic review of the literature to assess outcomes data on complications associated with implant-based breast reconstruction performed before or after chest wall radiation to assist in guiding the decision-making process for reconstruction of the irradiated breast.

METHODS

Studies from a PubMed search that met predetermined inclusion criteria were identified and included. Complications of interest were low- and high-grade capsular contractures, minor and major complications, reconstruction failure rates, and reconstruction completion rates. Pooled complication rates were calculated.

RESULTS

A total of 26 articles were included in the study after screening 1,006 publications, with 14 studies presenting data on prereconstruction radiation and 23 studies presenting data on postreconstruction radiation. Complication rates evaluated in patients exposed to radiation before or after implant reconstruction were not significantly different. Reconstruction failure rates were similar at 19 and 20 % for pre- and postreconstruction radiation patients, respectively. Completion rates were similar at 83 and 80 % for pre- and postreconstruction radiation patients, respectively.

CONCLUSIONS

Review of the current literature suggests similar overall success and failure rates with radiotherapy provided both before and after reconstruction. Failure rates in both groups of patients are clinically significant when considering implant reconstruction in the setting of radiation.