Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction

CXCL12-Targeted Immunomodulatory Gene Therapy Reduces Radiation-Induced Fibrosis in Healthy Tissues

Radiation-induced fibrosis (RIF) is a progressive pathology deleteriously impacting cancer survivorship. CXCL12 is an immune-stromal signal implicated in fibrosis and innate response. We hypothesized that modulation of CXCL12 would phenotypically mitigate RIF. CXCL12 expression was characterized in a rodent model of RIF and its expression modulated by the intravascular delivery of lentiviral vectors encoding small hairpin RNA to silence (LVShCXCL12) or overexpress (LVOeCXCL12) CXCL12. Multimodal fibrotic outcomes were quantified, and flow cytometry and Y-chromosome lineage-tracking studies performed to examine cellular recruitment and activation after radiotherapy. Whole-tissue RNA sequencing was used to examine matrisomal response. MATBIII tumors were engrafted within tissues with differing levels of CXCL12 expression, and tumoral response to RT was evaluated. CXCL12 was upregulated in irradiated fibroblasts demonstrating DNA damage after radiotherapy, which led to the recruitment of CD68+ macrophages. Silencing CXCL12 with LVShCXCL12 demonstrated reduced RIF phenotype as a result of decreased macrophage recruitment. Transcriptomic profiling identified osteopontin (OPN; SPP1) as being highly differentially expressed in LVShCXCL12-treated tissues. Tumors growing in tissues devoid of CXCL12 expression responded better after RT because of reductions in peritumoral fibrosis as a result of decreased CXCL12 and OPN expression at the tumor/normal tissue interface. This was also associated with greater CD8+ T-cell infiltration in tumors with less fibrosis. Antibody-mediated OPN blockade slowed tumor growth by increased intratumoral CD8+ T-cell activation. The CXCL12/OPN axis is an important node of immune/matrisomal cross-talk in the development of fibrosis. Therapeutic manipulation of this axis may offer greater antitumor efficacy while also reducing adverse effects.

Comparison of outcomes following postmastectomy radiation therapy in patients with autologous free flap reconstruction depending on the radiation therapy protocol: Systematic review and meta-analysis

BACKGROUND

Changes in the standard postmastectomy radiation therapy (PMRT) dosage schedule have led to the development of the hypofractionated radian therapy technique (HRT) that allows patients to receive fewer radian therapy sessions with higher doses in each session. Additionally, advancements in technology introduced the intensity-modulated radiation therapy (IMRT) technique to the widely used three-dimensional conformal radiation therapy. This review aimed to investigate the influence of radiation therapy protocols that may alter the postoperative outcomes of autologous free flap reconstruction.

METHODS

We reviewed the literature using MEDLINE and Embase databases for articles investigating outcomes of free flap autologous breast reconstruction in patients who underwent PMRT. The main search terms were synonyms of "radiation," "autologous," and either "immediate" and/or "delayed." Exclusion criteria included articles without a radiation protocol and dose. Cochrane risk of bias tool was used for bias assessment.

RESULTS

Studies were identified and analyzed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Overall, 238 papers underwent abstract screening and 112 underwent full-text screening, and 19 studies were extracted. The HRT group had significantly fewer postoperative complications than the conventional radian therapy (CRT) group (12.6% and 36.6%, respectively, P < 0.001). Further subgroup analyses were performed by including immediate and delayed breast reconstruction and radiation techniques including IMRT.

DISCUSSION

A remarkable decrease in postoperative complication rate in HRT was noted. HRT is considered a superior option for free flap reconstructive outcomes over CRT in patients with breast cancer after immediate and delayed breast reconstructions. Flap fibrosis was more prevalent in immediate breast reconstructions. However, aesthetic revision rates were comparable.

Fat grafting in breast surgery: a retrospective single-breast centre 6-year experience

PURPOSE

In recent years, fat grafting has gained importance as a valuable technique in breast surgery. As a breast center that has embraced this approach, we aimed to investigate the indications and complications of fat grafting.

METHODS

In this retrospective study, we examined a total of 263 lipofilling treatments on 121 patients. Five groups were identified: the reconstruction group (72.7%), consisting of 24.8% autologous and 38% implant-based reconstructions after cancer, and correction of the tuberous breasts (10.7%). An almost equivalent group (10.7%), consisted of patients treated for cosmetic reasons. Patients after breast-conserving therapy amounted to 16.5%. Twenty patients (16.5%) were treated to alleviate pain.

RESULTS

No major complications, and no cancer recurrence or metastasis were observed. One case of infection occurred at the injection site (infection rate: 0.38%). ANOVA showed statistically significant results for age (p < 0.001) and mean fat volume (p = 0.001). Posthoc analysis showed that the mean age of the tuberous group (21 years) was significantly smaller compared to all other categories (p < 0.001). Post-hoc analysis for fat volume indicated that the mean value for the cosmetic category (447.08 cc) was significantly greater than that of the breast-conserving and implant reconstruction categories (p = 0.009 and p = 0.030, respectively), while not significantly different from the tuberous and autologous reconstruction categories (p = 0.928 and p = 0.648, respectively).

CONCLUSIONS

Lipofilling has proven a valuable adjunct in reconstructive and aesthetic breast surgery with a low complication profile. The versatility of this low-cost technique and the low rate of complications make it a powerful asset of modern breast centers.

The Role of Density in Achieving Volume and Weight Symmetry in Breast Reconstruction

BACKGROUND

 Knowledge of tissue and implant density is crucial in obtaining both volume and weight symmetry in unilateral breast reconstruction. Therefore, the aim of this study was to determine and compare the density of abdominal and breast tissue specimens as well as of 5th generation breast implants.

METHODS

 Thirty-one breast tissue and 30 abdominal tissue specimens from 61 patients undergoing either mammaplasty or abdominoplasty as well as five different 5th generation breast implants were examined. Density (g/mL) was calculated by applying the water displacement method.

RESULTS

 The mean specimen density was 0.94 ± 0.02 g/mL for breast tissue and 0.94 ± 0.02 g/mL for abdominal tissue, showing no significant difference (p = 0.230). Breast tissue density significantly (p = 0.04) decreased with age, while abdominal tissue did not. A regression equation to calculate the density of breast tissue corrected for age (breast density [g/mL] = 0.975-0.0007 * age) is provided. Breast tissue density was not related to body mass index, past pregnancy, or a history of breastfeeding. The breast implants had a density ranging from 0.76 to 1.03 g/mL which differed significantly from breast tissue density (-0.19 g/mL [-19.8%] to +0.09 g/mL [+9.58%]; p ≤ 0.001).

CONCLUSION

 Our results support the suitability of abdominal-based perforator flaps in achieving both volume and weight symmetry in unilateral autologous breast reconstruction. Abdominal flap volume can be derived one-to-one from mastectomy weight. Further, given significant brand-dependent density differences, the potential to impose weight disbalances when performing unilateral implant-based reconstructions of large breasts should be considered.

Longitudinal Volume Assessment of Reconstructed Breast Using Three-Dimensional Measurement: How Do DIEP and LD Flap Change Immediately after Surgery?

Background  The deep inferior epigastric perforator (DIEP) and latissimus dorsi (LD) flaps are two widely used autologous breast reconstructions. Despite studies on flap-volume changes, the time of the first measurement is not immediately after surgery. Therefore, this study aimed to investigate the change in volume over time from the immediate postoperative period using a three-dimensional (3D) scanner. Methods  Patients who underwent breast reconstruction with a DIEP or LD flap between October 2019 and December 2020 at Showa University Koto Toyosu Hospital were included. The Kinect 3D scanner was used to measure the reconstructed and healthy breast volumes immediately after surgery and at 1, 3, 6, and 12 months. The control group was the healthy side, and the volumes obtained at each time point and ratios (to the immediate postoperative period) were calculated and analyzed using a linear mixed model. Results  Of the 25 patients and 26 breasts examined, the postoperative increase in volume ratios was statistically significant in the DIEP flap group, except for the sixth month, but decreased significantly in the LD group. Compared with the control group, the volume ratio was significantly higher up to 3 months in the DIEP flap group and decreased significantly after 3 months in the LD flap group. Conclusions  The volume of the LD flap continued to decrease immediately after surgery, whereas the volume of the DIEP flap increased by 10% up to 1M. Therefore, this increase in volume should be taken into consideration in studies where the initial measurements were not taken immediately after surgery.

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.

Nipple Projection Change in Immediate Breast Reconstruction and Use of an Acellular Dermal Matrix Strut for Maintaining Nipple Projection

BACKGROUND

Nipple-sparing mastectomy (NSM) has gained popularity as more studies have supported its oncologic safety. Although there have been some studies reporting complications including mastectomy flap and nipple necrosis, there have been few reports discussing the change in nipple projection following NSM. This study aimed to analyze the change in nipple projection after NSM and identify risk factors for nipple depression. In addition, the authors present a new method for maintaining nipple projection.

METHODS

Patients who underwent NSM between March of 2017 and December of 2020 at the authors' institute were included in this study. The authors measured the preoperative and postoperative nipple projection height and used a nipple projection ratio (NPR) to compare the change in height. Univariate and multivariate analyses were performed to examine the correlation of variables with the NPR.

RESULTS

A total of 307 patients and 330 breasts were included in this study. There were 13 cases of nipple necrosis. The postoperative nipple height was decreased by 32.8%, which was statistically significant. In multiple linear regression analysis, the use of an acellular dermal matrix strut was positively correlated with the NPR and implant-based reconstruction and postmastectomy radiation therapy were negatively correlated with the NPR.

CONCLUSIONS

The results of this study demonstrated that the reduction in nipple height after NSM was statistically significant. Surgeons need to be aware of these changes following NSM and explain this possibility to patients who have risk factors. The application of an acellular dermal matrix strut should be considered for the prevention of nipple reduction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Influence of Different Irradiation Regimens on Inflammation and Vascularization in a Random-Pattern Flap Model

BACKGROUND

Irradiation plays an important role in the oncological treatment of various tumor entities. The aim of the study was to investigate the influence of different irradiation regimens on random-pattern flaps at the molecular and histopathological levels.

METHODS

Twenty-five rats underwent harvesting of bilateral random-pattern fasciocutaneous flaps. The right flaps received irradiation, while the left flaps served as non-irradiated intraindividual controls. Five rats served as a non-irradiated control group. Four different irradiation regimens with give rats each were tested: 20 Gy postoperatively, 3 × 12 Gy postoperatively, 20 Gy preoperatively, and 3 × 12 Gy preoperatively. Two weeks after surgery, HE staining and immunohistochemical staining for CD68 and ERG, as well as PCR analysis to detect Interleukin 6, HIF-1α, and VEGF, were performed.

RESULTS

A postoperative cumulative higher dose of irradiation appeared to result in an increase in necrosis, especially in the superficial layers of the flap compared to preoperative or single-stage irradiation. In addition, we observed increased expression of VEGF and HIF-1α in all irradiation groups.

CONCLUSION

Even though no statistically significant differences were found between the different groups, there was a tendency for fractional postoperative irradiation with a higher total dose to have a more harmful effect compared to preoperative or single-dose irradiation.

Volume changes in the reconstructed breast over two years after free abdominal tissue transfer: Comparison of unipedicled versus bipedicled flaps

BACKGROUND

Volume changes in reconstructed flaps, particularly regarding symmetry, are an important consideration to improve long-term esthetic results in patients who undergo breast reconstruction. Asian patients with thin abdominal tissues tend to require bipedicled flaps, which provide a greater volume of abdominal tissue. We investigated volume changes in free abdominal flaps and the factors that may affect flap volume, particularly the number of pedicles.

METHODS

The study included all consecutive patients who underwent immediate unilateral breast reconstruction using free abdominal flaps between January 2016 and December 2018. The initial flap volume was calculated intraoperatively, and the postoperative flap volume was calculated using computed tomography or magnetic resonance imaging based on the Cavalieri principle.

RESULTS

The study included 131 of 249 patients. Compared with the initial inset volume, the mean flap volumes at 1 and 2 years postoperatively decreased to 80.11% and 73.80%, respectively. The multivariable analysis of factors that affect flap volume showed a significant association with the flap inset ratio, radiation (P = .019,.040, respectively). Stratification based on the number of pedicles showed that the flap inset ratio was significantly negatively correlated with the postoperative flap volume change in unipedicled (P < .05) but not in bipedicled flaps.

CONCLUSIONS

The flap volume decreased over time, and its change had a negative correlation with the flap inset ratio in the unipedicled group. Therefore, prediction of postoperative volume changes in various clinical situations is important before breast reconstruction.

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.

Techniques of inserting deep inferior epigastric perforator flap obliquely in immediate breast reconstruction after total mastectomy

Objective

This study aimed to share the experience of inserting a deep inferior epigastric perforator (D.I.E.P) flap obliquely in immediate breast reconstruction after total mastectomy.

Method

Forty patients underwent immediate breast reconstruction with flap D.I.E.P after total mastectomy. The flaps were placed obliquely, with the upper edge facing downward and inward. After being placed in the recipient region, parts of the flap at both ends were removed, the upper end was fixed into the II-III intercostal space next to the sternum, and the lower end was folded to create a projection of the lateral lower pole of the breast. The flap pedicle was anastomosed to the thoracodorsal vessels (TDVs) if the contralateral flap pedicle was used; conversely, the mammary vessels (IMVs) were used. Satisfaction with breast shape was assessed after 6 months using the BREAST-Q questionnaire.

Results

A total of 37/40 flaps were well vascularized; 36/37 patients with a survival flap were interviewed, showing that the average BREAST-Q evaluation score of satisfaction with breast shape was 62.22 (51-78). The number of answers for satisfied and very satisfied with breast shape accounted for 94.44%.

Conclusion

Inserting the D.I.E.P flap obliquely has the advantage of being easy to shape the breast contour, creating a moderate projection and symmetry to the opposite breast. The author suggested using the IMVs as the receiving vessels when using the pedicle of the flap on the ipsilateral side and the TDVs when the contralateral pedicle flap was used.

Breast Reconstruction- Developing a Volumetric Outcome Algorithm

Postoperative loss of breast volume represents a significant parameter for outcome evaluation of breast reconstruction. Breast volume broadly varies- depending of reconstruction method as well as surgical differences. A structural pattern of breast volume loss provides an essential parameter for preoperative design, helps to reduce postoperative breast asymmetry rate and thereby the need for reoperation. Therefore we hereby compare volume change of the three main reconstruction techniques: autologous flap-based, prosthesis-based and autologous fat transplantation breast reconstruction. LEVEL OF EVIDENCE V: 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 .

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.

Chronological flap volume and distribution changes after reconstruction of total maxillectomy defect using a rectus abdominis myocutaneous flap

BACKGROUND/PURPOSE

After total or subtotal maxillectomy, reconstruction using a free rectus abdominis myocutaneous (RAMC) flap is a fundamental and useful option. The purpose of the present study was to clarify the degree of flap volume change and volume distribution change with time after total or subtotal maxillectomy and free RAMC flap reconstruction and to examine the factors affecting the results.

METHODS

A total of 20 patients who underwent total or subtotal maxillectomy with free RAMC flap reconstruction were examined, and the flap volume change rate (volume at final evaluation [POD 181-360] / volume at initial evaluation [POD 5-30]) was investigated using the results of imaging tests. Moreover, the flap was divided into four blocks (A-D) in the cranio-caudal direction, and the volume change of each block was individually analyzed.

RESULTS

The overall volume change rate of fat/muscle/total was 0.84 ± 0.21/0.36 ± 0.08/0.67 ± 0.15, at the mean follow-up period of 309±35 days after the operation. The multiple regression analysis revealed that weight loss (for fat), postoperative RT (for fat and muscle), and young age (for muscle) were independently associated with flap volume loss. The results also indicated that the fat volume was stable, whereas the muscle volume decreased to <40% over time, assuming there were no influencing factors. Regarding flap volume distribution change, the fat volume tended to gather toward the central-cranial direction, while the muscle volume gathered toward the cranial direction, and total flap volume gathered toward the central direction.

Volume Change of Muscle and Fat Portions of Latissimus Dorsi Myocutaneous Flap after Breast Reconstruction

Background

Myocutaneous flaps are composed of muscle and fat portions, and exhibit volume changes with time. However, no consideration is generally given to volume changes of muscle and fat portions occurring in the flap. Therefore, we conducted this study to analyze the volume changes of muscle and fat portions of pedicled latissimus dorsi myocutaneous flaps over time.

Methods

Sixteen patients who underwent breast reconstruction using a latissimus dorsi myocutaneous flap between 2009 and 2017 were enrolled in this study. Using their postoperative computed tomography scan data, we measured the volume of muscle and fat portions of the flap, and performed a statistical analysis of volume changes over time. We also measured the volume of latissimus dorsi muscle on the opposite side and compared the difference in muscle volume.

Results

The volume of the muscle portion of latissimus dorsi myocutaneous flap decreased by approximately 24%, from 6 months to postoperative year 2; from the third year, it shrank with a decrease rate similar to that of normal muscle. The fat portion of the flap showed no regular volume changes.

Conclusions

Atrophy of the muscle portion is the primary cause of volume change of latissimus dorsi myocutaneous flaps over time. it is necessary to understand the difference in the volume change patterns of the muscle and fat. To maintain a long-term satisfactory result, it is better to make the maximum possible use of the relatively stable fat portion rather than the muscle portion.

Magnitude of radial forearm free flaps and factors associated with loss of volume in oral cancer reconstructive surgery: Prospective study

BACKGROUND

Adequate flap volume is key to maintaining oral function after oral cancer surgery. This study aimed to evaluate changes in radial forearm free flap (RFFF) volumes after 1 year of follow-up following ablative tumor surgery in the head and neck.

METHODS

A prospective study that recorded the clinical data of 20 patients with head and neck cancer who underwent RFFF reconstruction. Magnetic resonance (MR) and Mimics Research 19.0 software were used to measure the RFFF volumes at 1, 3, 6, and 12 postoperative months.

RESULTS

Compared with one postoperative month, the RFFF volume decreased by 15.5%, 29.4%, and 42.0% at 3, 6, and 12 months, respectively, after surgery. A significant positive correlation between postoperative radiotherapy and RFFF volume changes was detected.

CONCLUSION

The volume of RFFF decreases with time. It is recommended to use overcorrection, with a 40% increase in RFFF volume, to reconstruct head and neck tumor-related defects.

"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.

A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy

BACKGROUND

 Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known.

METHODS

 A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT.

RESULTS

 Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group.

CONCLUSION

 Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.