Effects of Radiation Therapy on Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Implant-based reconstruction and adjuvant radiotherapy in breast cancer patients-current status and DEGRO recommendations

PURPOSE

The aim of this review is to give an overview of the results of prospective and retrospective studies using allogenic reconstruction and postmastectomy radiotherapy (PMRT) in breast cancer and to make recommendations regarding this interdisciplinary approach.

MATERIALS AND METHODS

A PubMed search was conducted to extract relevant articles from 2000 to 2024. The search was performed using the following terms: (breast cancer) AND (reconstruction OR implant OR expander) AND (radiotherapy OR radiation). Data from the literature on allogenic breast reconstruction and radiation are presented and discussed in relation to toxicity and cosmesis.

CONCLUSION AND RECOMMENDATIONS

Breast reconstruction is also feasible if PMRT is necessary. Patients need to be informed about the relevant risk of capsular fibrosis and implant failure. A planned reconstruction is no reason to forgo PMRT nor is an indication for PMRT a reason to forego implant-based breast reconstruction if desired by the patient. It is important to provide detailed information here to enable shared decision-making. There is still no clear consensus regarding implant-based reconstruction (IBR) and PMRT. However, in clinical practice, both a one-stage (immediate "implant-direct" IBR) procedure with PMRT up to the final implant and a two-stage (immediate-delayed IBR) procedure with PMRT up to the tissue expander (TE) and later exchange of the TE are used; both approaches have their specific advantages and disadvantages. Depending on patient-specific factors and the surgeon's experience and estimates, both IBR procedures are also possible in combination with PMRT. When using a TE/implant approach, completing skin stretching by adequately filling the expander before PMRT may be favorable. This approach is particularly practical when adjuvant chemotherapy is planned but may lead to postponement of radiotherapy when primary systemic therapy is given. According to the latest data, moderate hypofractionation also appears to be safe in the context of the IBR approach. It is important to have a closely coordinated interdisciplinary approach and to fully inform patients about the increased rate of potential side effects.

Contemporary Issues in Postmastectomy Radiotherapy: A Brief Review

Breast cancer is the one of the most common cancers and causes a significant disease burden. Currently, postmastectomy radiotherapy (PMRT) is indicated for breast cancer patients with higher risk of recurrence, such as those with positive surgical margins or high-risk breast cancer (T3 with positive lymph nodes, ≥4 positive lymph nodes or T4 disease). Whether PMRT should be used in intermediate-risk breast cancer (T3 with no positive lymph nodes or T1-2 with 1-3 positive lymph nodes) is contentious. Rates of breast reconstruction postmastectomy are increasing in countries like Australia, and PMRT usage in such settings is another area of active research. Ongoing trials are also assessing the safety and efficacy of hypofractionated PMRT, a clinical scenario now widely accepted for early-stage breast cancer. This brief review is unique in that it aims to examine three current and controversial aspects of the PMRT field (PMRT in intermediate-risk breast cancer, PMRT in conjunction with breast reconstruction and its hypofractionation). To achieve this aim, we discuss available and emerging literature and guidelines to offer insights important to the PMRT field. Current literature suggests that PMRT could play a role in improving the overall survival rate and in reducing locoregional recurrence in intermediate-risk breast cancer. In terms of recommending a timing or type of breast reconstruction best suited to the setting of PMRT, we found that individual patient preferences and circumstances need to be considered alongside a multidisciplinary approach. Research into PMRT hypofractionation safety and efficacy is ongoing and its place remains to be elucidated.

Outcomes of Immediate versus Delayed Autologous Reconstruction with Postmastectomy Radiation: A Meta-Analysis

BACKGROUND

Postmastectomy autologous breast reconstruction can be immediate or delayed. The safety of performing immediate breast reconstruction (IBR) and the impact of radiation on the newly reconstructed breast is not yet validated.

METHODS

A PubMed, Embase, and Google scholar search was conducted from inception to September 17, 2023. The authors included comparative studies that assessed complications or aesthetic outcomes of IBR versus delayed breast reconstruction (DBR) in the setting of postmastectomy radiotherapy (PMRT).

RESULTS

The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy, whereas 699 had DBR. Mean follow-up time and age for both groups were comparable ( P > 0.1). None of the complications-revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing-were significantly different across groups ( P > 0.1). IBR was found to have a higher risk of flap fibrosis (OR, 28.18; 95% CI, 5.15 to 154.12; P = 0.0001; I2 = 44%) and skin flap necrosis (OR, 6.12; 95% CI, 2.71 to 13.82; P < 0.0001; I2 = 27%) but a lower risk of partial flap failure (OR, 0.18; 95% CI, 0.06 to 0.58; P = 0.004; I2 = 0%) when compared with DBR. Results of fat necrosis should be interpreted with caution. Patient-reported and objective aesthetic outcomes were mostly comparable between groups.

CONCLUSIONS

IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires.

The Impact of Timing of Delayed Autologous Breast Reconstruction following Postmastectomy Radiation Therapy on Postoperative Morbidity

BACKGROUND

 The ideal time to perform reconstruction after the completion of postmastectomy radiation therapy (PMRT) in patients with locally advanced breast cancer is currently unknown. We evaluate the association between the timing of delayed autologous breast reconstruction following PMRT and postoperative complications.

METHODS

 Patients who underwent mastectomy, PMRT, and then delayed autologous breast reconstruction from 2009 to 2016 were identified from the Truven Health MarketScan Research Databases. Timing of reconstruction following PMRT was grouped 0-3, 3-6, 6-12, 12-24, and after 24 months. Multivariable models were used to assess associations between timing of reconstruction following PMRT and key measures of morbidity.

RESULTS

 A total of 1,039 patients met inclusion criteria. The rate of any complications for the analytic cohort was 39.4%, including 13.3% of patients who experienced wound complications and 11.3% of patients requiring additional flaps. Unadjusted rates of complications increased from 23.4% between 0 and 3 months to 49.4% between 3 and 6 months and decreased thereafter. Need for additional flaps was highest within 3 to 6 months (14.0%). Multivariate analysis revealed higher rates of any complications when reconstruction was performed between 3 and 6 months (odds ratio [OR]: 3.04, p < 0.001), 6 and 12 months (OR: 2.66, p < 0.001), or 12 and 24 months (OR: 2.13, p = 0.001) after PMRT. No difference in complications were noted in reconstructions performed after 24 months compared with those performed before 3 months (p > 0.05). However, rates of wound complications were least likely in reconstructions after 24 months (OR: 0.34, p = 0.035).

CONCLUSION

 These findings suggest plastic surgeons may consider performing autologous breast reconstruction early for select patients, before 3 months following PMRT without increasing postoperative morbidity.

Visual Perception of Breast Free Flap Size Is Influenced by Radiation Changes of Surrounding Tissue

BACKGROUND

 Microsurgical reconstruction for bilateral mastectomy defects after unilateral radiation often results in asymmetry, despite both flap tissues never being radiated.

METHODS

 Photos of 16 patients who received prior radiation to one breast and underwent bilateral abdominal free flap reconstruction were taken postoperatively. Layperson and expert assessment were attained via online crowdsourcing and a panel of attending surgeons and senior residents. Stratification by interflap weight differences was done for subanalysis.

RESULTS

 A total of 399 laypersons responded, with the majority (57.3%) reporting that the radiated breast appeared smaller than the nonradiated breast. When the photos were stratified by interflap weight differences, the photos with the radiated side flap weight over 3% more than nonradiated side were significantly more likely to be perceived by laypersons as the same size (odds ratio [OR] = 2.7; p < 0.001) and of similar aesthetic (OR = 1.9; p < 0.001) when compared with photos with same-sized flaps. Of the expert responses (n = 16), the radiated side was perceived as smaller 72.3% of the time and the nonradiated side appeared more aesthetic 52.7% of the time. Contrary to layperson responses, the experts tend to report the radiated side as smaller despite varying flap weight. Interestingly, expert raters were significantly more likely to rate the flaps of equal aesthetics when the radiated side has a flap larger by 3% or more (OR = 3.6; p < 0.001).

CONCLUSION

 Higher aesthetic scores were noted when larger flaps were inset to the radiated envelope by both laypersons and experts, suggesting potential technical refinement in reconstructive outcomes.

Impact of Adjuvant Radiotherapy on Free Flap Volume in Autologous Breast Reconstruction: A Scoping Review

In autologous breast reconstruction, a sufficient flap volume is fundamental to restore breast shape and ensure an aesthetic outcome. After mastectomy, postoperative irradiation is regularly indicated in the oncological treatment algorithm. When administering radiation therapy after autologous reconstruction, the tissue transferred is inherently irradiated. Although there is evidence that points to a reduction in flap volume after adjuvant radiotherapy, the data have been contradicting and inconclusive. To address this anecdotal evidence, we performed a scoping review of the current literature that addresses the effect of radiotherapy on breast flap volume. Six two-armed studies, comprising a total of 462 patients, reported on the effect of adjuvant radiotherapy on free flap volume changes. Of those, two studies found a significant negative impact of radiotherapy on free flap volume, while the other four studies did not. Reported flap volume changes ranged from no change to a reduction of 26.2%, measured up to two years postoperatively. The selected studies contain varying patient numbers, follow-up timepoints, types of flaps, and measuring methods, contributing to a relatively high heterogeneity. While we present some evidence suggesting a significant impact of adjuvant radiotherapy on breast flap volume, future studies are needed to further investigate this potential correlation.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data

BACKGROUND

 While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality.

METHODS

 The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed.

RESULTS

 A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified.

CONCLUSION

 Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

[Update and Trends in Breast Reconstruction After Mastectomy]

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

Post-Mastectomy Tissue Expander Placement Followed by Radiation Therapy: A Cost-Effectiveness Analysis of Staged Autologous Versus Implant-Based Unilateral Reconstruction

BACKGROUND

There is no preferred approach to breast reconstruction for patients with locally advanced breast cancer (LABC) who require post-mastectomy radiation therapy (PMRT). Staged implant and autologous reconstruction both have unique risks and benefits. No previous study has compared their cost-effectiveness with utility scores.

METHODS

A literature review determined the probabilities and outcomes for mastectomy and staged implant or autologous reconstruction. Utility scores were used to calculate the quality-adjusted life years (QALYs) associated with successful surgery and postoperative complications. Medicare billing codes were used to assess costs. A decision analysis tree was constructed with rollback and incremental cost-effectiveness ratio (ICER) analyses. Sensitivity analyses were performed to validate results and account for uncertainty.

RESULTS

Mastectomy with staged deep inferior epigastric perforator (DIEP) flap reconstruction is costlier ($14,104.80 vs $3216.93), but more effective (QALYs, 29.96 vs 24.87). This resulted in an ICER of 2141.00, favoring autologous reconstruction. One-way sensitivity analysis showed that autologous reconstruction was more cost-effective if less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective.

CONCLUSIONS

For patients with LABC who require PMRT, staged autologous reconstruction is significantly more cost-effective than reconstruction with implants. Despite the decreased morbidity, staged implant reconstruction has greater rates of complication.

Total breast reconstruction with the fat-augmented latissimus dorsi (FALD) flap: High safety in a single-center uncontrolled case series

According to ASPS, 107,238 breast reconstructions (BR) have been performed in the United States this year. The latissimus dorsi (LD) flap is used for breast reconstruction (BR), either with an implant or an extended flap harvest. Implant-enhanced LD is associated with 50% reoperation rates. To avoid implant-related complications, we introduced the Fat-Augmented LD (FALD) flap. Several authors report 92% patient satisfaction and 36% complication rates (CR). The aim of our study is to present a single-center uncontrolled case series with long follow-up assessing CR and esthetic results. Women with small-to-moderate breasts requiring immediate or delayed BR were included, whereas athletic and paraplegic women or patients with contraindication for free flap BR were excluded. Clinical and surgical data were analyzed. Esthetic analysis was performed using a panel of independent observers. Between December 2010 and November 2019, 100 patients underwent 148 FALD-based BR. Average operative time was 193.5 min for unilateral procedure and 290.6 min for bilateral procedure. Mean immediate AFT volume was 105.3 cc (range 60-170) per breast. Major complication (total or partial flap necrosis > 30%) rate was 0%, and minor complication (partial flap necrosis < 30%, fat necrosis hematoma, seroma, donor site dehiscence, and chronic pain) rate was 6.76%. Esthetic analysis garnered satisfactory results for all types of mastectomies. For variables regarding skin texture (p = 0.001), scar location (p = 0.005), and total score (p = 0.001), patients undergoing Modified Radical Mastectomy scored lower than Skin-Sparing Mastectomy and Nipple-Sparing Mastectomy. We were able to confirm that the FALD flap is a safe with a low complication rate and high patient satisfaction. Level of Evidence IV.

Long-Term Clinical and Aesthetic Results of a Systematic Fat Transfer Protocol for Total Breast Reconstruction after Nipple-Sparing Mastectomy

BACKGROUND

Autologous fat transfer can be safely offered for total breast reconstruction after nipple-sparing mastectomy. The aim of this study was to extend a fat transfer protocol to smokers and compare the long-term results among them and irradiated and nonirradiated patients.

METHODS

One hundred seventeen breasts after nipple-sparing mastectomy were prospectively enrolled and stratified in group A (25 irradiated), group B (21 smokers), or group C (71 controls). A standardized fat transfer protocol was used. Data collected were patient demographics, surgery information, and aesthetic analysis. Continuous and categorical variables were analyzed with the Kruskal-Wallis test, and the Cohen Kappa test was used to test interrater variability for the aesthetic analysis.

RESULTS

Groups were homogeneous for demographics ( p > 0.05) but significantly different in number of fat transfer sessions ( p < 0.001), mean volume of the first two treatments ( p = 0.003), and mean total volume of injected fat ( p = 0.002). Volume, shape, position of the breast mound, inframammary fold, and scar location subscales obtained high score evaluations without a significant difference among groups ( p > 0.05), whereas skin texture subscale showed a lower score evaluation in group A ( p = 0.003). Although a significant difference for total subscales was worse in group A ( p = 0.004), the global score had a high rate evaluation in all groups ( p = 0.145). Interrater reliability showed substantial agreement among all categories.

CONCLUSION

Although further investigation is required, the authors confirm the efficacy of their fat transfer protocol for both irradiated and nonirradiated nipple-sparing mastectomy patients and propose its indication to smokers with comparable clinical and aesthetic results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

[Breast Reconstruction Strategies in Case of Planned Radiotherapy]

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.

Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis

BACKGROUND

There is great uncertainty regarding the practice of immediate autologous breast reconstruction (IBR) when post-mastectomy radiotherapy (PMRT) is indicated. Plastic surgery units differ in their treatment protocols, with some recommending delayed breast reconstruction (DBR) following PMRT. IBR offers significant cosmetic and psychosocial benefits; however, the morbidity of flap exposure to radiation remains unclear.

OBJECTIVE

The aim of this review was to comprehensively analyze the existing literature comparing autologous flaps exposed to PMRT and flaps with no radiation exposure.

METHODS

A comprehensive search in MEDLINE, EMBASE and CENTRAL databases was conducted in November 2020. Primary studies comparing IBR with and without adjuvant PMRT were assessed for the following primary outcomes: clinical complications, observer-reported outcomes and patient-reported satisfaction rates. Meta-analysis was performed to obtain pooled risk ratios of individual complications.

RESULTS

Twenty-one articles involving 3817 patients were included. Meta-analysis of pooled data gave risk ratios for fat necrosis (RR = 1.91, p < 0.00001), secondary surgery (RR = 1.62, p = 0.03) and volume loss (RR = 8.16, p < 0.00001) favoring unirradiated flaps, but no significant difference was observed in all other reported complications. The no-PMRT group scored significantly higher in observer-reported measures. However, self-reported aesthetic and general satisfaction rates were similar between groups.

CONCLUSION

IBR should be offered after mastectomy to patients requiring PMRT. The higher risks of fat necrosis and contracture appear to be less clinically relevant as corroborated by positive scores from patients developing these complications. Preoperative and intraoperative measures should be taken to further optimize reconstruction and mitigate post-radiation sequel. Careful management of patients' expectations is also imperative.

LEVEL OF EVIDENCE

Level III.

Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options

Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.

Optimal reconstructive strategies in the setting of post-mastectomy radiotherapy - A systematic review and network meta-analysis

BACKGROUND

A third of breast cancer patients require mastectomy. In some high-risk cases postmastectomy radiotherapy (PMRT) is indicated, threatening reconstructive complications. Several PMRT and reconstruction combinations are used. Autologous flap (AF) reconstruction may be immediate (AF→PMRT), delayed-immediate with tissue expander (TE [TE→PMRT→AF]) or delayed (PMRT→AF). Implant-based breast reconstruction (IBBR) includes immediate TE followed by PMRT and conversion to permanent implant (PI [TE→PMRT→PI]), delayed TE insertion (PMRT→TE→PI), and prosthetic implant conversion prior to PMRT (TE→PI→PMRT).

AIM

Perform a network metanalysis (NMA) assessing optimal sequencing of PMRT and reconstructive type.

METHODS

A systematic review and NMA was performed according to PRISMA-NMA guidelines. NMA was conducted using R packages netmeta and Shiny.

RESULTS

16 studies from 4182 identified, involving 2322 reconstructions over three decades, met predefined inclusion criteria. Studies demonstrated moderate heterogeneity. Multiple comparisons combining direct and indirect evidence established AF-PMRT as the optimal approach to avoid reconstructive failure, compared with IBBR strategies (versus PMRT→TE→PI; OR [odds ratio] 0.10, CrI [95% credible interval] 0.02 to 0.55; versus TE→PMRT→PI; OR 0.13, CrI 0.02 to 0.75; versus TE→PI→PMRT OR 0.24, CrI 0.05 to 1.05). PMRT→AF best avoided infection, demonstrating significant improvement versus PMRT→TE→PI alone (OR 0.12, CrI 0.02 to 0.88). Subgroup analysis of IBBR found TE→PI→PMRT reduced failure rates (OR 0.35, CrI 0.15-0.81) compared to other IBBR strategies but increased capsular contracture.

CONCLUSION

Immediate AF reconstruction is associated with reduced failure in the setting of PMRT. However, optimal reconstructive strategy depends on patient, surgeon and institutional factors. If IBBR is chosen, complication rates decrease if performed prior to PMRT.

PROSPERO REGISTRATION

CRD 42020157077.

A Study on Breast Reconstruction in a Developing Country: A Comprehensive Evaluation of the Techniques and Oncologic Outcomes

BACKGROUND

Breast cancer, with an incidence of 33.2 per 100,000 in Iranian population, is considered as the most common cancer in Iranian women. Nowadays, with the increasing survival rates, breast reconstruction has been integrated into surgical techniques of breast cancer treatment. The aim of this study was to evaluate the current status of breast reconstruction in Iranian population.

PATIENTS AND METHODS

This retrospective study was conducted in Imam Hospital between January 2008 and June 2018. All the patients underwent breast reconstruction surgery. The trend of reconstruction and complication rates were 2 major outcomes. Logistic regression model was used to predict complications. Student t test was used to compare means.

RESULTS

Fifty-five patients underwent 60 autologous breast reconstruction surgeries and 152 patients underwent 193 prosthesis-based reconstruction surgeries. Most of cases were invasive ductal carcinoma ± ductal carcinoma in situ (126 cases, 68%). Among 253 surgeries in 207 patients, 98 cases (38.7%) were 2-stage implant, 91 (36.0%) were 1-stage implant, 3 (1.2%) were acellular dermal matrix + prosthesis, 31 (12.2%) were pedicled transverse rectus abdominis myocutaneous flap, 25 (9.8%) were latissimus dorsi flap ± prosthesis, and 4 (15.8%) were latissimus dorsi flap. Among prosthesis-based reconstructions, chemotherapy could predict the occurrence of complications (odds ratio, 2.87; 95% CI, 1.07-7.68), whereas none of these factors could predict the occurrence of complications in autologous reconstructions. The most prevalent complication was seroma formation (48.5% of all complications). Overall complication rates (including major and minor) were higher among autologous reconstructions compared with prosthesis-based reconstructions (45.8% and 21.1%, respectively, P < 0.001).

CONCLUSIONS

The trend of breast reconstruction is changing in Islamic Republic of Iran as a developing country. Implant-based reconstruction has surpassed autologous reconstructions in recent years. In terms of complications, we observed higher rates among autologous reconstructions.

"Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy"

BACKGROUND

Immediate post-mastectomy autologous breast reconstruction in breast cancer patients requiring post-mastectomy radiation therapy (PMRT) minimizes the number of operations that patients must undergo and alleviates the psychological impact of living without a breast. However, the safety and impact of radiation on the reconstructed breast remains to be established. This study aimed to compare immediate versus delayed autologous reconstruction in the setting of PMRT to determine the optimal sequencing of reconstruction and adjuvant radiation.

METHODS

A systematic review of the literature identified 292 studies meeting criteria for full-text review, 44 of which underwent meta-analysis. This represented data on 1,927 immediate reconstruction (IR) patients and 1,546 delayed reconstruction (DR) patients (3,473 total patients). Early complications included flap loss, fat necrosis, thrombosis, seroma, hematoma, infection, and skin dehiscence. Late complications included fibrosis or contracture, severe asymmetry, hyperpigmentation, and decreased flap volume.

RESULTS

Immediate breast reconstruction did not demonstrate significantly increased complication rates. Reported mean complication rates in IR versus DR groups, respectively, were fat necrosis 14.91% and 8.12% (p = 0.076), flap loss 0.99% and 1.80% (p = 0.295), hematoma 1.91% and 1.14% (p = 0.247), infection 11.66% and 4.68% (p = 0.155), and thrombosis 1.51% and 3.36% (p = 0.150). Seroma rates were significantly lower in the immediate cohort at 2.69% versus 10.57% in the delayed cohort (p = 0.042).

CONCLUSION

Complication rates are comparable between immediate and delayed breast reconstruction in the setting of PMRT. Given the patient benefits incurred by an IR algorithm, immediate autologous breast reconstruction should be considered as a viable treatment option in patients requiring PMRT.

Breast Reconstruction and Radiation Therapy

Purpose:

The optimal approach to the integration of postmastectomy reconstruction and radiation therapy is not well-established. This review will summarize current literature pertaining to the most common types of reconstruction in the setting of postmastectomy radiation therapy (PMRT).

Data Sources:

Literature from PubMed was reviewed from 2000 to 2016.

Study Selection:

Studies were selected with relevance to “postmastectomy breast reconstruction,” “breast reconstruction,” and “breast reconstructive methods and PMRT.” Surgical outcomes, patient satisfaction, and cost-effectiveness were examined.

Data Extraction:

Data from publications was extracted, summarized, and converted to a table.

Results of Data Synthesis:

Implant-based techniques are on the rise, in the setting of PMRT. Implant-based methods are more affordable in the short term and result in immediate breast-mound formation compared to autologous methods. When compared to implant-based reconstruction with PMRT, autologous reconstruction with PMRT results in better quality of life (QoL) and sensory recovery as well as fewer complications and failures. Among autologous flaps, deep inferior epigastric perforator flaps are considered superior to transverse rectus abdominal muscle (TRAM) pedicled flaps and may be more suitable for PMRT. Latissimus dorsi and muscle-sparing free TRAM flaps are also viable options. In delayed autologous, which may be advantageous for high-risk patients, the optimal timing to delay surgery after radiation therapy is unknown. Reconstruction with a 2-stage tissue expander-implant technique offers good to excellent cosmetic outcomes in the setting of PMRT, although there may be complications in this 2-stage process.

Conclusion:

Surgical, cosmetic, quality of life, and life expectancy must be taken into account when selecting the way to integrate breast reconstruction and PMRT.

Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?

PURPOSE

There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population.

METHODS

A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes.

RESULTS

Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey.

CONCLUSIONS

Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study

BACKGROUND

Previous studies suggest that immediate reconstruction following mastectomy produces superior results over delayed procedures. However, for medical or oncological reasons, some patients may be poor candidates for immediate reconstruction. We compared complications and patient-reported outcomes between immediate and delayed breast reconstructions in a prospective, multicenter study.

METHODS

1957 patients (1806 immediate, 151 delayed) met eligibility criteria. Demographic data, major complications, infections, and reconstructive failure rates were evaluated. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys, pre- and two years post-operatively. Subscale scores were compared across cohorts using mixed-effects regression models, controlling for patient characteristics and hospitals.

FINDINGS

Complete data were available in 1639 immediate and 147 delayed reconstruction patients. There were significant baseline differences between immediate and delayed cohorts in age, BMI, prevalence of diabetes, lymph node management, use of radiation, and chemotherapy. Controlling for clinical covariates, the delayed group had lower odds of any (OR 0.38, p < 0.001) and major (OR 0.52, p = 0.016) complications, compared with immediate patients. Furthermore, delayed reconstruction was associated with a significantly lower failure rates (6% vs. 1.3%, p = 0.032). However, multivariate analyses found no significant differences in patient satisfaction or in psychosocial, sexual, or physical well-being at two years.

CONCLUSIONS

Compared with immediate techniques, delayed reconstruction following mastectomy was associated with lower rates of overall and major complication, while providing equivalent patient satisfaction and quality of life benefits. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delaying reconstruction does not appear to compromise clinical or patient-reported outcomes.

Comparison of Wound Complications After Immediate, Delayed, and Secondary Breast Reconstruction Procedures

Importance

Few data are available concerning surgical site infection (SSI) and noninfectious wound complications (NIWCs) after delayed (DR) and secondary reconstruction (SR) compared with immediate reconstruction (IR) procedures in the breast.

Objective

To compare the incidence of SSI and NIWCs after implant and autologous IR, DR, and SR breast procedures after mastectomy.

Design, Setting, and Participants

This retrospective cohort study included women aged 18 to 64 years undergoing mastectomy from January 1, 2004, through December 31, 2011. Data were abstracted from a commercial insurer claims database in 12 states and analyzed from January 1, 2015, through February 7, 2017.

Exposures

Reconstruction within 7 days of mastectomy was considered immediate. Reconstruction more than 7 days after mastectomy was considered delayed if the mastectomy did not include IR or secondary if the mastectomy included IR.

Main Outcomes and Measures

International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI and NIWCs.

Results

Mastectomy was performed in 17 293 women (mean [SD] age, 50.4 [8.5] years); 61.4% of women had IR or DR. Among patients undergoing implant reconstruction, the incidence of SSI was 8.9% (685 of 7655 women) for IR, 5.7% (21 of 369) for DR, and 3.2% (167 of 5150) for SR. Similar results were found for NIWCs. In contrast, the incidence of SSI was similar after autologous IR (9.8% [177 of 1799]), DR (13.9% [19 of 137]), and SR (11.6% [11 of 95]) procedures. Compared with women without an SSI after implant IR, women with an SSI after implant IR were significantly more likely to have another SSI (47 of 412 [11.4%] vs 131 of 4791 [2.7%]) and an NIWC (24 of 412 [5.8%] vs 120 of 4791 [2.5%]) after SR. The incidence of SSI (24 of 379 [6.3%] vs 152 of 5286 [2.9%]) and NIWC (22 of 379 [5.8%] vs 129 of 5286 [2.4%]) after implant SR was higher in women who had received adjuvant radiotherapy. Wound complications after IR were associated with significantly more breast surgical procedures (mean of 1.92 procedures [range, 0-9] after implant IR and 1.11 [range, 0-6] after autologous IR) compared with women who did not have a complication (mean of 1.37 procedures [range, 0-8] after implant IR and 0.87 [range, 0-6] after autologous IR).

Conclusions and Relevance

The incidence of SSI and NIWCs was slightly higher for implant IR compared with delayed or secondary implant reconstruction. Women who had an SSI or NIWC after implant IR had a higher risk for subsequent complications after SR and more breast operations. The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy.

Tolerance of latissimus dorsi in immediate breast reconstruction without implant to radiotherapy

INTRODUCTION

Immediate breast reconstruction (IBR) improves the quality of life of patients who undergo mastectomy. The latissimus dorsi flap (LDF) method provides particularly good aesthetic results, but its tolerance to subsequent radiotherapy remains unclear. We thus sought to assess tolerance and esthetic results and satisfaction, as reported by patients who underwent IBR by LDF with or without subsequent radiotherapy.

MATERIALS AND METHODS

We performed a retrospective case-control study in a population of women who were diagnosed with breast cancer between January 1999 and January 2014 and who had mastectomies with IBR by LDF without prostheses. We paired 29 patients who needed postoperative radiotherapy to 58 control patients who did not. These patients responded to a questionnaire to evaluate tolerance and their satisfaction with the aesthetic results of the reconstruction.

RESULTS

In total, 86.2% of all patients reported "very good" or "good" overall aesthetic satisfaction. Consistency was judged as "very good" or "good" by 82.7% of control patients and by 93.1% of case patients. No statistically significant differences were identified between the two groups with regard to reconstruction results. The number of surgical procedures needed did not differ significantly between the two groups.

CONCLUSION

In our study, IBR by LDF appeared to have excellent tolerance to subsequent radiotherapy, the latter having no impact on patient aesthetic satisfaction. Our results suggest that the possibility of postoperative radiotherapy should not prevent physicians from proposing this method to women who are candidates for it.

An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction

INTRODUCTION

Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT. This offers uniform distribution of standard radiation doses, thereby minimizing radiation-induced changes while maintaining oncologic safety. We present our 8-year experience with the custom bolus approach for PMRT delivery in immediate autologous breast reconstruction.

METHODS

All immediate autologous breast reconstruction patients requiring PMRT after 2006 were treated with the custom bolus approach. Retrospective chart review was performed to compare the postirradiation complications, reconstruction outcomes, and oncologic outcomes of these patients with those of previous patients at our institution who underwent standard bolus, and to historical controls from peer-reviewed literature.

RESULTS

Over the past 10 years, of the 29 patients who received PMRT, 10 were treated with custom bolus. Custom bolus resulted in fewer radiation-induced skin changes and less skin tethering/fibrosis than standard bolus (0% vs 10% and 20% vs 35%, respectively), and less volume loss and contour deformities compared with historical controls (10% vs 22.8% and 10% vs 30.7%, respectively).

CONCLUSIONS

Custom bolus PMRT minimizes radiation delivery to the internal mammary vessels, anastomoses, and skin; uniformly doses the surgical incision; and provides the necessary radiation dose to prevent recurrence. Because custom bolus PMRT may reduce the deleterious effects of radiation on reconstructive outcomes while maintaining safe oncologic results, we encourage all plastic surgeons to collaborate with radiation oncologists to consider this technique.

Optimizing Breast Cancer Adjuvant Radiation and Integration of Breast and Reconstructive Surgery

Postmastectomy radiotherapy (PMRT) reduces the risk of locoregional and distant recurrence and improves overall survival in women with lymph node-positive breast cancer. Because of stage migration and improvements in systemic therapy and other aspects of breast cancer care, the absolute benefit of PMRT and regional nodal irradiation may be small in some favorable subsets of patients with very low nodal burden, and newer consensus guidelines do not mandate PMRT in all node-positive cases. The use and need for PMRT may considerably complicate breast reconstruction after mastectomy and therefore mandates multidisciplinary input that takes into account patient choice given potential risk of acute and long-term toxicities, benefits, life expectancy, the biology of the tumor, plans for systemic therapy, and actual tumor burden. Management of axillary lymph node metastases is changing with selective use of axillary lymph node dissection for advanced disease, sentinel lymph node biopsy alone for clinically and pathologic node-negative cases receiving mastectomy, and targeted axillary dissection alone among patients with eradication of initial biopsy-proven nodal metastases with neoadjuvant systemic therapy use. In general, when the need for PMRT is anticipated, autologous reconstruction should be delayed. This comprehensive article reviews the current indications and implications regarding integration of breast cancer surgery and timing of reconstruction with optimum radiation delivery to achieve the best possible patient outcomes.

Effect of Previous Irradiation on Vascular Thrombosis of Microsurgical Anastomosis: A Preclinical Study in Rats

BACKGROUND

The objective of the present investigation was to compare the effect of neoadjuvant irradiation on the microvascular anastomosis in cervical bundle using an experimental model in rats.

METHODS

One hundred forty male Sprague-Dawley rats were allocated into 4 groups: group I, control, arterial microanastomosis; group II, control, venous microanastomosis; group III, arterial microanastomosis with previous irradiation (20 Gy); and group IV, venous microanastomosis with previous irradiation (20 Gy). Clinical parameters, technical values of anastomosis, patency, and histopathological parameters were evaluated.

RESULTS

Irradiated groups (III and IV) and vein anastomosis groups (II and IV) showed significantly increased technical difficulties. Group IV showed significantly reduced patency rates (7/35) when compared with the control group (0/35). Radiotherapy significantly decreased the patency rates of the vein (7/35) when compared with the artery (1/35). Groups III and IV showed significantly reduced number of endothelial cells and also showed the presence of intimal thickening and adventitial fibrosis as compared with the control group.

CONCLUSION

Neoadjuvant radiotherapy reduces the viability of the venous anastomosis in a preclinical rat model with a significant increase in the incidence of vein thrombosis.

Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy

BACKGROUND

Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER).

METHODS

A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test.

RESULTS

There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P < 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts.

CONCLUSIONS

This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients' potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction.

Effect of Noninfectious Wound Complications after Mastectomy on Subsequent Surgical Procedures and Early Implant Loss

BACKGROUND

Noninfectious wound complications (NIWCs) after mastectomy are not routinely tracked and data are generally limited to single-center studies. Our objective was to determine the rates of NIWCs among women undergoing mastectomy and assess the impact of immediate reconstruction (IR).

STUDY DESIGN

We established a retrospective cohort using commercial claims data of women aged 18 to 64 years with procedure codes for mastectomy from January 2004 through December 2011. Noninfectious wound complications within 180 days after operation were identified by ICD-9-CM diagnosis codes and rates were compared among mastectomy with and without autologous flap and/or implant IR.

RESULTS

There were 18,696 procedures (10,836 [58%] with IR) among 18,085 women identified. The overall NIWC rate was 9.2% (1,714 of 18,696); 56% required surgical treatment. The NIWC rates were 5.8% (455 of 7,860) after mastectomy only, 10.3% (843 of 8,217) after mastectomy plus implant, 17.4% (337 of 1,942) after mastectomy plus flap, and 11.7% (79 of 677) after mastectomy plus flap and implant (p < 0.001). Rates of individual NIWCs varied by specific complication and procedure type, ranging from 0.5% for fat necrosis after mastectomy only, to 7.2% for dehiscence after mastectomy plus flap. The percentage of NIWCs resulting in surgical wound care varied from 50% (210 of 416) for mastectomy plus flap, to 60% (507 of 843) for mastectomy plus implant. Early implant removal within 60 days occurred after 6.2% of mastectomy plus implant; 66% of the early implant removals were due to NIWCs and/or surgical site infection.

CONCLUSIONS

The rate of NIWC was approximately 2-fold higher after mastectomy with IR than after mastectomy only. Noninfectious wound complications were associated with additional surgical treatment, particularly in women with implant reconstruction, and with early implant loss.

Breast reconstruction following conservative mastectomies: predictors of complications and outcomes

Breast reconstruction can be performed using a variety of techniques, most commonly categorized into an alloplastic approach or an autologous tissue method. Both strategies have certain risk factors that influence reconstructive outcomes and complication rates. In alloplastic breast reconstruction, surgical outcomes and complication rates are negatively impacted by radiation, smoking, increased body mass index (BMI), hypertension, and prior breast conserving therapy. Surgical factors such as the type of implant material, undergoing immediate breast reconstruction, and the use of fat grafting can improve patient satisfaction and aesthetic outcomes. In autologous breast reconstruction, radiation, increased BMI, certain previous abdominal surgery, smoking, and delayed reconstruction are associated with higher complication rates. Though a pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the most common type of flap used for autologous breast reconstruction, pedicled TRAMs are more likely to be associated with fat necrosis than a free TRAM or deep inferior epigastric perforator (DIEP) flap. Fat grafting can also be used to improve aesthetic outcomes in autologous reconstruction. This article focuses on factors, both patient and surgical, that are predictors of complications and outcomes in breast reconstruction.

Does acellular dermal matrix really improve aesthetic outcome in tissue expander/implant-based breast reconstruction?

BACKGROUND

The expectation for improved results by women undergoing postmastectomy reconstruction has steadily risen. A majority of these operations are tissue expander/implant-based breast reconstructions. Acellular dermal matrix (ADM) offers numerous advantages in these procedures. Thus far, the evidence to justify improved aesthetic outcome has solely been based on surgeon opinion. The purpose of this study was to assess aesthetic outcome following ADM use in tissue expander/implant-based breast reconstruction by a panel of blinded plastic surgeons.

METHODS

Mean aesthetic results of patients who underwent tissue expander/implant-based breast reconstruction with (n = 18) or without ADM (n = 20) were assessed with objective grading of preoperative and postoperative photographs by five independent blinded plastic surgeons. Absolute observed agreement as well as weighted Fleiss Kappa (κ) test statistics were calculated to assess inter-rater variability.

RESULTS

When ADM was incorporated, the overall aesthetic score was improved by an average of 12.1 %. In addition, subscale analyses revealed improvements in breast contour (35.2 %), implant placement (20.7 %), lower pole projection (16.7 %), and inframammary fold definition (13.8 %). Contour (p = 0.039), implant placement (p = 0.021), and overall aesthetic score (p = 0.022) reached statistical significance. Inter-rater reliability showed mostly moderate agreement.

CONCLUSIONS

Mean aesthetic scores were higher in the ADM-assisted breast reconstruction cohort including the total aesthetic score which was statistically significant. Aesthetic outcome alone may justify the added expense of incorporating biologic mesh. Moreover, ADM has other benefits which may render it cost-effective. Larger prospective studies are needed to provide plastic surgeons with more definitive guidelines for ADM use.

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 .

Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals

BACKGROUND

Achieving an aesthetic outcome following postmastectomy breast reconstruction is both an important goal for the patient and plastic surgeon. However, there is currently an absence of a widely accepted, standardized, and validated professional aesthetic assessment scale following postmastectomy breast reconstruction.

METHODS

A systematic review was performed to identify all articles that provided professional assessment of the aesthetic outcome following postmastectomy, implant- or autologous tissue-based breast reconstruction. A modified version of the Scientific Advisory Committee's Medical Outcomes Trust (MOT) criteria was used to evaluate all professional aesthetic assessment scales identified by our systematic review. The criteria included conceptual framework formation, reliability, validity, responsiveness, interpretability, burden, and correlation with patient-reported outcomes.

RESULTS

A total of 120 articles were identified: 52 described autologous breast reconstruction, 37 implant-based reconstruction, and 29 both. Of the 12 different professional aesthetic assessment scales that exist in the literature, the most commonly used scale was the four-point professional aesthetic assessment scale. The highest score on the modified MOT criteria was assigned to the ten-point professional aesthetic assessment scale. However, this scale has limited clinical usefulness due to its poor responsiveness to change, lack of interpretability, and wide range of intra- and inter-rater agreements (Veiga et al. in Ann Plast Surg 48(5):515-520, 2002).

CONCLUSIONS

A "gold standard" professional aesthetic assessment scale needs to be developed to enhance the comparability of breast reconstruction results across techniques, surgeons, and studies to aid with the selection of procedures that produce the best aesthetic results from both the perspectives of the surgeon and patients.

Total breast reconstruction using autologous fat grafting following nipple-sparing mastectomy in irradiated and non-irradiated patients

BACKGROUND

Although autologous microvascular reconstruction following nipple-sparing mastectomy (NSM) is considered one of the best reconstructive choices, this procedure cannot be offered to all patients. The aim of this study was to define a fat grafting protocol for successful reconstruction following NSM and to assess its reliability in irradiated and non-irradiated patients.

MATERIALS AND METHODS

Twenty-one patients were prospectively enrolled and stratified in Group-A (11 non-irradiated) and Group-B (10 irradiated) NSMs comparing clinical and aesthetic outcomes. A fat grafting protocol was used to standardize the procedure. Continuous and categorical variables were analysed using the Student t test and the Kruskal-Wallis test, respectively. A value of p ≤ 0.05 was considered statistically significant.

RESULTS

The groups were homogeneous in terms of demographics (p > 0.05), while number of sessions, mean volume of the first two treatments, and overall injected volume showed significant differences (p < 0.001; p < 0.001; p = 0.002). Volume, shape, position of the breast mound, IMF and scar location subscales obtained high score evaluations without a significant difference between the groups (p > 0.05), whereas the skin texture subscale showed a lower score evaluation in Group-B than in Group-A (p = 0.001). Although a significant difference for total subscales was in favour of Group-A (p = 0.001), the global score had a high rate evaluation in both groups (p = 0.132). Inter-rater reliability showed substantial agreement among all categories, total and global scores.

CONCLUSIONS

To the best of our knowledge, this is the first prospective series of fat transfer reconstructions following NSM using a systematic approach. Although further studies are required, it may be considered an effective option whenever flap reconstruction cannot be performed.

LEVEL OF EVIDENCE III

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.

Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap

BACKGROUND

Irradiation to free flaps following immediate breast reconstruction has been shown to compromise outcomes. The authors hypothesized that irradiated muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps experience less fat necrosis than irradiated deep inferior epigastric perforator (DIEP) flaps.

METHODS

The authors performed a retrospective study of all consecutive patients undergoing immediate, autologous, abdomen-based free flap breast reconstruction with muscle-sparing free TRAM or DIEP flaps over a 10-year period at their institution. Irradiated flaps (external-beam radiation therapy) after immediate breast reconstruction were compared with nonirradiated flaps. Logistic regression analysis identified potential associations between patient, tumor, and reconstructive characteristics and surgical outcomes.

RESULTS

The analysis included 625 flaps: 40 (6.4 percent) irradiated versus 585 (93.6 percent) nonirradiated. Mean follow-up for the irradiated and nonirradiated flaps was 60.0 and 48.5 months, respectively (p = 0.02). Overall complication rates were similar for both the irradiated and nonirradiated flaps. Irradiated flaps (i.e., both DIEP and muscle-sparing free TRAM flaps) developed fat necrosis at a significantly higher rate (22.5 percent) than the nonirradiated flaps (9.2 percent; p = 0.009). There were no differences in fat necrosis rates between the DIEP and muscle-sparing free TRAM flaps in both the irradiated and nonirradiated groups.

CONCLUSIONS

Both DIEP and muscle-sparing free TRAM flap reconstructions had much higher rates of fat necrosis when irradiated. Contrary to our hypothesis, the authors found that immediate breast reconstruction with a muscle-sparing free TRAM flap does not result in a lower rate of fat necrosis than reconstruction with a DIEP flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal?

PURPOSE

The specific aim of this study was to conduct a systematic review of the literature to assess outcomes data on complications and aesthetic results associated with autologous tissue-based breast reconstruction performed before or after chest wall irradiation.

METHODS

Studies from a PubMed search that met predetermined inclusion criteria were identified. Complications of interest included partial or total flap loss, fat necrosis, thrombosis, infection, seroma, hematoma, delayed wound healing, and flap fibrosis/contracture. Pooled complication rates were calculated.

RESULTS

A total of 20 articles were included in the study for autologous reconstruction. These primary articles were selected after screening 897 publications, with six studies presenting data on pre-reconstruction radiation, nine studies presenting data on post-reconstruction radiation, and five studies presenting data on both patient groups. Comparison of pooled complication rates between flaps irradiated before or after reconstruction were statistically similar, including total flap loss (1 vs. 4 %), wound healing complications (10 vs. 14 %), infection (4 vs. 6 %), hematoma (2 vs. 1 %), seroma (4 vs. 4 %), and fat necrosis (10 vs. 13 %). The pooled rate of flap contracture and fibrosis was 27 % in flap reconstructions exposed to radiotherapy. Statistical evaluation of aesthetic outcomes was impossible as a result of variability in assessment and reporting methods.

CONCLUSIONS

Review of the current literature suggests similar rates of complications and success rates in autologous breast reconstruction patients exposed to pre- or post-reconstruction radiation. Immediate autologous reconstruction should be considered as a viable option even in patients who are likely to require postmastectomy radiotherapy.