Bilateral Breast Reconstruction Research Articles

Long-Term Outcomes following Hybrid Breast Reconstruction.

Hybrid breast reconstruction combines free tissue transfer with implant placement. Various mesh products have been successfully used to secure the implant position in these reconstructions. In this study, the authors investigate the impact of mesh type on long-term outcomes following hybrid breast reconstruction. A retrospective analysis of all patients with at least 24 months of follow-up after immediate bilateral prepectoral hybrid breast reconstruction was performed. Univariate and multivariable regression analyses were used to evaluate long-term outcomes and compare breasts reconstructed with polyglactin mesh versus acellular dermal matrix (ADM). Thirty-nine patients (78 breasts) who underwent hybrid breast reconstruction with an average follow-up period of 50.4 months (range, 27 to 73 months) were included in the study. Postoperative complications included hematoma ( n = 2 [2.6%]), mastectomy skin necrosis ( n = 12 [15.4%]), and fat necrosis ( n = 6 [7.7%]). There were no instances of implant infection, implant exposure, or flap failure. Polyglactin mesh and ADM were used in 24 breasts and 54 breasts, respectively. Implant malposition and capsular contracture occurred more frequently in the polyglactin cohort leading to 10 (41.7%) instances of reoperation for implant replacement compared with only 1 (1.9%) in the ADM cohort ( P < 0.001). On multivariable regression analysis, polyglactin mesh was associated with a 36-fold greater probability of requiring implant replacement compared with ADM ( P = 0.006). ADM (versus polyglactin mesh) is associated with lower rates of capsular contracture and implant malposition in the context of hybrid breast reconstruction. Therapeutic, III.

The Delay Procedure in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

The delay procedure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review the authors' experience with this technique, evaluate the indications, and analyze the surgical outcomes. A retrospective study was conducted of all consecutive DIEP delay procedures performed between March of 2019 and June of 2021. Patient demographic characteristics, operative details, and complications were registered. Patients had preoperative imaging by magnetic resonance angiography to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation, the flaps were pedicled on a dominant perforator and a lateral skin bridge extending toward the lateral flank and lumbar fat; in a second stage, the flap was harvested and transferred. A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation, seroma was the most frequently observed complication (7.3%). After the second operation, three total flap losses (1.9%) were observed. The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert cases previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction. Therapeutic, IV.

The impact of using the internal mammary artery as a recipient vessel on medial mastectomy skin flap perfusion in autologous breast reconstruction: An observational study using indocyanine green

The internal mammary artery (IMA) is the preferred recipient vessel for microvascular anastomosis in immediate autologous breast reconstruction following skin-sparing mastectomy (SSM). Although the IMA accounts for approximately 60% of the blood supply to the breast, the exact contribution to the mastectomy skin flap perfusion is unclear. The aim of this observational study was to investigate the impact of using the IMA as a recipient vessel on medial mastectomy skin flap perfusion assessed with indocyanine green angiography (ICGA). This observational study included ten consecutive women who underwent immediate autologous breast reconstructions following SSM. Two intraoperative indocyanine green (ICG) assessments were performed to assess tissue perfusion of the upper and lower part of the medial mastectomy skin flap: the first following the SSM and the second after clamping the IMA. During a 120-second angiography, three additional images were made after 60, 90, and 120s. The ICG inflow time and mean, minimum, and maximum fluorescence intensities (FIs) were obtained. Four unilateral and six bilateral autologous breast reconstructions were included. There was no difference in tissue perfusion when comparing the inflow time (24.1s vs. 23.0s, P=0.348), the mean FI (131.4 vs. 124.0, P=0.126), minimum FI (28.6 vs. 33.4, P=0.086), and maximum FI (253.1 vs. 247.6, P=0.166) before and after clamping the IMA. According to this study, the use of the IMA as a recipient vessel does not reduce medial mastectomy skin flap perfusion in patients undergoing immediate autologous breast reconstructions following SSM.

Tumor de Masson en la mama: un reto diagnóstico

Papillary endothelial hyperplasia (PEH) or Masson's tumor is a rare benign vascular tumor that usually appears in the soft tissues of the head and neck, trunk and extremities, being extremely rare in the breast. Its diagnosis can be a challenge, especially in the follow-up of patients with previous disease of breast carcinoma. We present the case of a 65-year-old patient, with a history of bilateral breast cancer and reconstruction with implants, who presented a Masson's tumor during follow-up. An ultrasound scan was performed, showing a well-circumscribed mass in the left breast, located in the posterior contour of the implant. Subsequently, magnetic resonance imaging (MR) depicted an enhancing tumor, without infiltration of adjacent structures. Finally, the definitive anatomopathological diagnosis was obtained after surgical excision.

174. Autologous Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition

PURPOSE: The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when traditional abdominal donor sites are not available. Sociodemographic morphometric analyses have shown that the ideal waistline is characterized by a waist-to-hip ratio (WHR) of 0.7. How the LAP donor site affects truncal proportions and whether LAP flaps may lead to potential secondary benefits concerning waistline definition has never been systematically investigated. METHODS: A retrospective review of 50 patients who underwent bilateral breast reconstruction with lumbar artery perforator flaps (100 flaps) from 2018 - 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in WHR to assess waistline definition. The patients’ individual perception of postoperative aesthetic changes to their waistline was determined by an electronic survey. RESULTS: The patients had a mean age of 51 (24 - 63 years) and a mean BMI of 26.9 kg/m2 (19.3 - 37.4 kg/m2). Postoperative donor site complications included seromas (n = 10), wound dehiscence requiring operative revision (n = 5), hematomas (n = 4), and wound infections requiring oral antibiotic therapy (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have an improved waistline definition, indicated by a significantly decreased WHR (0.85 vs. 0.80, P = 0.005). Patient reported outcomes were obtained from 53% of patients. Among those, 81% of patients felt that their waistline had aesthetically improved after reconstruction, 14% reported no changes to their waistline aesthetics, and only 5% reported that their waistline had aesthetically worsened. CONCLUSION: Bilateral LAP flap breast reconstruction leads to improved waistline definition bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients that are not candidates for abdominal free flaps, however, demonstrate excess flank tissue and seek a more defined waistline.

Progression of the Deep Inferior Epigastric Perforator Flap Breast Reconstruction Technique at a Dedicated New Zealand Tertiary Plastic Surgery Unit: a Case Series Analysis

AbstractThe deep inferior epigastric perforator (DIEP) flap is the gold standard in post-mastectomy breast reconstruction. Improved patient outcomes, reduced operating time and reduced complication rates are reportedly observed over consecutive DIEP series within surgical centres. The aim of this study is to investigate whether outcomes following DIEP flap reconstruction improve over time, by assessing two patient cohorts undergoing the procedure at a microsurgical unit seven years apart. A case analysis was undertaken to identify all patients who underwent primary DIEP flap reconstruction in 2011 and 2018. Outcomes recorded included clinic appointments, operating time, number of primary operations, additional operations and procedures, along with co-morbidities, BMI and radiotherapy rates. Immediate versus delayed and unilateral versus bilateral breast reconstruction was also recorded. Seven patients underwent primary DIEP reconstruction in 2011 and 29 in 2018. There was a significant reduction in additional operations performed in 2018 (p-value = 0.007) and a significant reduction in number of procedures (p-value = 0.043). When adjusted for an outlier, the total operating time for unilateral DIEP reconstruction was significantly shorter in 2018 (p-value = 0.018), along with reduced primary and total operating time for 2018 bilateral reconstructions. The 2018 cohort also had lower complication rates and fewer clinic appointments. This study illustrates how outcomes can improve with experience of DIEP flap reconstruction. The more complex DIEP flap requires investment in terms of skill acquisition and operative time, but is balanced by improvement in patient outcomes.

D134. Comparison of Nipple-sparing Mastectomy versus Skin-sparing Mastectomy in Bilateral Implant-based Breast Reconstruction with Unilateral Radiotherapy: A Matched Cohort Study

PURPOSE: Nipple-sparing mastectomy (NSM) preserves natural nipple-areola complex and entire native breast skin with a goal of better cosmetic outcomes in breast reconstruction. In bilateral tissue expander (TE)/implant-based reconstruction requiring unilateral post-mastectomy radiotherapy (PMRT), progressive radiation-induced fibrosis can lead to increasing nipple asymmetry with cosmetic dissatisfaction. Thus, PMRT may ultimately negate the intended positive cosmetic value of NSM compared to skin-sparing mastectomy (SSM). This study compares, 1) surgical complications, 2) patient satisfaction, and 3) aesthetic outcomes between NSM vs. SSM in bilateral implant-based reconstruction with unilateral PMRT. METHOD: This retrospective matched cohort study included consecutive NSM patients with TE/implant breast reconstruction + unilateral PMRT matched 1:2 to SSM group. All patients completed PMRT and TE exchange to implants. Demographics, oncologic stage, co-morbidities, and complication data were collected. Patient satisfaction was evaluated by BREAST-Q. Aesthetic outcome was assessed by blinded reviewers with a 5-point Likert scale. RESULTS: Among 58 patients who underwent bilateral TE/implant reconstruction with unilateral PMRT, 17 NSM patients were matched to 41 SSM patients by age, BMI, and co-morbidities. No significant difference existed between overall surgical complications (p=0.2) and BREAST-Q questionnaire scores. The average adverse effects of radiation score was higher in the NSM. Preliminary aesthetic outcomes demonstrated higher total average aesthetic score in SSM compared to NSM. CONCLUSION: Although NSM is generally associated with better cosmetic outcome compared to SSM, it has far less impact in bilateral implant-based breast reconstruction with unilateral PMRT. This may be related to the additional negative post-radiotherapy impact on nipple asymmetry.

D142. Concurrent Co-surgeon DIEP Flap Breast Reconstructions: Feasibility and Clinical Outcomes

PURPOSE: A co-surgeon model has been shown to be a favorable approach for microvascular breast reconstruction, but concurrent co-surgeon DIEP flap cases have not been well-studied. The authors hypothesize that performing two concurrent co-surgeon bilateral DIEP flap reconstructions would increase productivity and result in non-inferior clinical outcomes. METHODS: A single-institution, retrospective cohort study was designed utilizing electronic medical record review to identify all cases of co-surgeon free flap breast reconstructions over a 38-month period. Subsequently, study patients who specifically underwent concurrent bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-concurrent reconstruction within the same, preceding, or following month of those in the study group. Primary outcome variables were minor and major complications within 90-days postoperatively. Secondary outcome variables were operating time and length of hospital stay. Descriptive statistics, univariate analysis, and multivariate regression analysis were performed. RESULTS: 137 subjects were identified, and 64 met inclusion criteria (n=28 study group, n=36 control). There was no statistically significant difference between the groups in age, BMI, radiation, trainee experience, or immediate/delayed reconstruction. There was no statistically significant difference in minor and major complications including anastomosis revision, takeback to operating room, or readmission. Operative time was longer in the study group (540.5 vs. 451.7 minutes, p<0.0001). There was no statistically significant difference in length of hospital stay. CONCLUSION: Concurrent co-surgeon approach to bilateral DIEP flap breast reconstruction increases productivity and does not result in a higher complication rate, compared to non-concurrent operations.

BREAST-Q and Donor Site Comparison in Bilateral Stacked Autologous Breast Reconstruction

Introduction: Patients undergoing bilateral autologous breast reconstruction may benefit from increased flap volume using bilateral stacked deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps. Our aim was to characterize the donor site morbidity and patient reported outcomes in four-flap breast reconstruction. Materials and Methods: Retrospective review was performed for all patients undergoing four-flap breast reconstruction by two surgeons between January 2010 – September 2021. Outcome measures including the BREAST-Q reconstructive module, the Lower Extremity Functional Scale (LEFS), inpatient surgical site pain scores by Numeric Pain Rating Scale (NPRS), and a post-operative subjective survey comparing donor sites were obtained. Four-flap BREAST-Q scores were compared to bilateral DIEP and to bilateral PAP patients. Results: A total of 79 patients undergoing four-flap breast reconstruction were identified. Four-flap BREAST-Q scores (n=56) were similar to bilateral DIEP and bilateral PAP reconstruction patients. Long term survey outcomes from the LEFS demonstrated improved score trend after 6 months. Mean instances of donor site pain location recorded at the abdomen were significantly higher than the thigh during the post-operative admission. Subjective survey data revealed more long-term donor site pain at the PAP site, a patient preference for the DIEP donor site, and easier post-operative care for the DIEP donor site. Conclusion: This is the largest consecutive series of four-flap breast reconstruction outcomes reported to date. BREAST-Q scores in four-flap patients demonstrate overall patient satisfaction that is similar to both bilateral DIEP and bilateral PAP reconstruction patients. The DIEP donor site appears to be preferred by patients than the PAP donor site.

Operative Time Is an Independent Predictor of Postoperative Outcomes in Bilateral DIEP Flap Breast Reconstruction: A Multivariate Analysis of 1000 Flaps

Introduction: Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT’s impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in Deep Inferior Epigastric Artery Perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds. Materials and Methods: Patients who underwent bilateral DIEP flaps from 2010-2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. 1000 flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. Results: After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all p<0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (p=0.050), 5-7 hours had comparable odds (p=0.540), and 7-9 hours had 5.5 times lower odds than procedures ≥ 9 hours (p<0.001). Lastly, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 x OT (hours) (R2=0.308; p<0.001). Conclusion: Operative time (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 hours and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.

Streamlining and Consistency in Surgery: Lean Six Sigma to Improve Operating Room Efficiency.

Improving perioperative efficiency helps reduce unnecessary surgical expenditure, increase operating room throughput, improve patient safety, and enhance staff and patient satisfaction. Lean Six Sigma (LSS) is a quality improvement model that has been successfully applied to eliminate inefficiencies in the business sector but has not yet been widely adopted in medicine. This study investigates the adaptation of LSS to improve operative efficiency for plastic surgery procedures. The authors followed the define, measure, analyze, improve, and control phases to implement LSS. The key outcome measures gathered were operative times, including the cut-to-close time, and the total time the patient spent in the operating room. The study included a total of 181 patients who underwent immediate bilateral deep inferior epigastric perforator flap breast reconstruction between January of 2016 and December of 2019. The LSS interventions were associated with a decrease in total operative time from 636.36 minutes to 530.35 minutes, and a decrease in the time between incision to closure from 555.16 minutes to 458.85 minutes for a bilateral mastectomy with immediate deep inferior epigastric artery flap breast reconstruction. This study demonstrates that LSS is useful to improve perioperative efficiency during complex plastic surgery procedures. The workflow of the procedure was improved by determining the optimal spatial positioning and distinct roles for each surgeon and preparing surgeon-specific surgical trays. Two process maps were developed to visualize the positioning of the surgeons during each stage of the procedure and depict the parallel workflow that helped improve intraoperative efficiency.

Using Virtual Reality for Deep Inferior Epigastric Perforator Flap Preoperative Planning.

This prospective case series feasibility study was conducted in two tertiary medical centers. Participants were women slated to undergo free transverse rectus abdominis muscle, unilateral or bilateral deep inferior epigastric perforator flap immediate breast reconstruction. Based on a routine CTA, a 3D VR model was generated. Before each procedure, the surgeons examined the CTA and then the VR model. Any new information provided by the VR imaging was submitted to a radiologist for confirmation before surgery. Following each procedure, the surgeons completed a questionnaire comparing the two methods. Thirty women between 34 and 68 years of age were included in the study; except for one, all breast reconstructions were successful. The surgeons ranked VR higher than CTA in terms of better anatomical understanding and operative anatomical findings. In 72.4% of cases, VR models were rated having maximum similarity to reality, with no significant difference between the type of perforator anatomical course or complexity. In more than 70% of the cases, VR was considered to have contributed to determining the surgical approach. In four cases, VR imaging modified the surgical strategy, without any complications. VR imaging was well-accepted by the surgeons who commented on its importance and ease compared with the standard CTA presentation. Further studies are needed to determine whether VR should become an integral part of preoperative deep inferior epigastric perforator surgery planning.

DIEP flap in breast reconstruction: A morbidity study of bilateral versus unilateral reconstruction

The Deep Inferior Epigastric Perforator (DIEP) flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction. A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis. A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (P=0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (P=0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (P=0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (P=1). This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral deep inferior epigastric perforator flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis. Prognostic/Risk Study, Level II.

Immediate bilateral breast reconstruction after skin-sparing mastectomy: cross-sectional incision and implants in mixed plane

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies.

Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction. O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported. Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m2. Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p<0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis. The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Keller Funnel Efficacy in "No Touch" Breast Augmentation and Reconstruction: A Systematic Review.

A systematic review of PubMed, Embase, the Cochrane database, and Google Scholar was performed between 2005 and 2021. All clinical-based, retrospective and prospective studies utilizing the Keller funnel method for breast implant insertion were selected. Six studies were identified for evaluation: five were retrospective cohorts and one was a prospective trial. No randomized controlled trials were found. Outcomes reported included lower rates of capsular contracture (RR, 0.42; P = 0.0006; 95% CI, 0.25-0.69), shorter incision lengths (35.5 ± 2.1 mm), less insertion time (mean = 6 seconds), and decreased complications, and one paper reported ultimately greater patient satisfaction with outcomes (BREAST-Q Score: 92%). This review suggests that the Keller funnel is a useful method for no-touch breast augmentation and reconstruction surgery. The Keller funnel reduces subsequent capsular contracture rate, surgical time, and incision length and allows for easier insertion. However, our findings support recommendation of a prospective randomized controlled clinical trial with larger population size and follow-up intervals.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients

Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions. We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data. A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference. We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

Nipple-Sparing Mastectomy and Immediate Reconstruction: A Propensity Score-Matched Analysis of Satisfaction and Quality of Life.

Although it is intuitive that nipple-sparing mastectomy in selected patients would result in excellent cosmetic outcomes and high patient satisfaction, studies of clinical outcomes and health-related quality of life are limited and show mixed results. This study aimed to use a propensity score-matching analysis to compare satisfaction and health-related quality-of-life outcomes in patients who underwent implant-based reconstruction following bilateral nipple-sparing mastectomy or skin-sparing mastectomy. A propensity score-matching analysis (1:1 matching, no replacement) was performed comparing patients undergoing nipple-sparing or skin-sparing mastectomy with immediate bilateral implant-based breast reconstruction. Patients with a history of any radiation therapy were excluded. Matched covariates included age, body mass index, race, smoking history, neoadjuvant chemotherapy, bra size, and history of psychiatric diagnosis. Outcomes of interest included BREAST-Q scores and complications. The authors examined 1371 patients for matching and included 460 patients (nipple-sparing mastectomy, n = 230; skin-sparing mastectomy, n = 230) in the final analyses. The authors found no significant differences in baseline, cancer, and surgical characteristics between matched nipple-sparing and skin-sparing mastectomy patients, who also had similar profiles for surgical complications. Interestingly, the authors found that postoperative Satisfaction with Breasts scores and all other health-related quality-of-life domains were stable over a 3-year period and did not differ significantly between the two groups. Compared with skin-sparing mastectomy, bilateral nipple-sparing mastectomy did not improve patient-reported or clinical outcomes when combined with immediate implant-based reconstruction. The impact that nipple-sparing mastectomy may have on breast aesthetics and the ability of the BREAST-Q to gauge an aesthetic result following nipple-sparing mastectomy warrant further investigation. Therapeutic, III.

Bilateral latissimus dorsi for breast reconstruction in one stage.

The authors present atechnique of bilateral breast reconstruction in case series of 5 patients, allowing simultaneous harvest of both latissimus dorsi myocutaneous flaps. Three patients underwent bilateral immediate reconstruction after prophylactic mastectomy. One patient underwent adelayed reconstruction, in 1 patient latissimus dorsi myocutaneous flap was used after prophylactic mastectomy and reconstruction with implants followed by bilateral necrosis of the skin flaps. The described technique enables safe breast reconstruction in one procedure. The average reconstruction time was about 4 hours, which represents bilateral latissimus dorsi procedure to the centre of the breast reconstructions range, between the reconstructions with double free tissue transfer and the breast implants.

Direct-to-Implant Breast Reconstruction After Unilateral and Bilateral Mastectomy: Cross-Sectional Study of Patient Satisfaction and Quality of Life with BREAST-Q.

Immediate single stage breast reconstruction is a challenging procedure with the goal of improving the quality of life of patients with breast cancer. The aim of this study is to evaluate using the BREAST-Q patient satisfaction, body perception and quality of life after direct-to-implant breast reconstruction comparing unilateral and bilateral reconstructions. In this study we enrolled 56 women who underwent mastectomy and immediate single-stage direct-to-implant (DTI) breast reconstruction at Campus Bio-Medico University of Rome between 2013 and 2020. One year after surgery they were administered electronically the BREAST-Q post-operative module. Our two cohorts of patients consisted in 34 women who received unilateral nipple-sparing mastectomy and DTI breast reconstruction and 22 women who underwent bilateral nipple-sparing mastectomy and DTI breast reconstruction. Twenty-four of the 34 patients belonging to the unilateral group responded to the questionnaire (70.5%), while in the bilateral group responders were 16 out of 22 (72.7%). The BREAST-Q scores were compared between the two groups: patients undergoing bilateral mastectomy and breast reconstruction showed higher scores in every BREAST-Q domain compared to patients undergoing unilateral mastectomy and breast reconstruction with a statistically significant difference in the Satisfaction with breast (P = 0.01), Sexual well-being (P = 0.03), and Satisfaction with implants (P = 0.01) domains. Patients undergoing bilateral DTI breast reconstruction have a favorable postoperative surgical cosmetic outcome with a better patient's body image perception and a higher post-operative level of satisfaction compared to unilateral DTI reconstruction after nipple-sparing mastectomy. 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.