Complete Breast Reconstruction Research Articles

Nipple-areola complex prosthesis as a new arsenal for breast reconstruction

Nipple and areola complex (NAC) recreating is primordial to achieve a complete breast reconstruction. Some patients would not benefit or choose to undergo surgical or tattoo NAC reconstruction. Recently, innovative NAC silicone prostheses have been developed that are applied over the skin and come in various shapes, sizes, and colors to match different NAC tones and sizes.Our prospective study aims to evaluate for the first time, to our knowledge, the safety of these prostheses and patients’ and surgeons’ satisfaction using a 30-day survey. Twenty patients using these NAC prostheses after unilateral breast reconstruction postmastectomy with NAC excision were included.All patients except one (95%) were satisfied/very satisfied with the aspect and symmetry of NAC prostheses compared with native contralateral NAC. All patients were more/much more satisfied with their body image and self-esteem using the NAC prostheses. Except for 2 (90%), no participant presented any skin reaction, infection, or erosion. Most patients (68.75%) used the prosthesis every day, and others—occasionally. All participants stated they would recommend these prostheses to other women as a temporary or definitive solution.With these promising results demonstrating a high safety and satisfaction rate, we are confident that this simple, safe, noninvasive, and cost-effective device should be proposed to all patients to improve the management of breast reconstruction and offer body integrity to patients. Health insurance should consider reimbursement for these prostheses in patients after mastectomy or with NAC deformation after trauma, surgery, or congenital.

Head-to-Head Analysis of Vertical vs Horizontal Incision Patterns in Breast Reconstruction: Surgical Outcomes and Aesthetic Implications.

Modern aesthetically optimized breast reconstruction requires collaboration between the patient, breast surgeon, and plastic surgeon. To optimize both surgical outcome and aesthetic results, incision patterns must be carefully planned. We aimed to determine whether vertical or horizontal orientation of mastectomy incision was preferred in the general population and to analyze corresponding complication profiles. A retrospective review was performed of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 to November 2022. Postoperative complications of the 2 incision patterns were analyzed. Additionally, crowdsourcing was utilized to assess aesthetic implications of horizontal and vertical incision patterns on postoperative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess differences in scoring based on voter characteristics. There were no significant differences in postoperative breast complications between patients with horizontal or vertical incisions when considering wound, infection, seroma, hematoma, fat necrosis, or overall complications (P > .05). Crowdsourcing showed that, regardless of voter demographics, vertical incisions were preferred over horizontal incisions (P < .001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (P < .001). Although there are no significant differences in complication profiles between vertical and horizontal incisions in autologous breast reconstruction patients, vertical incision patterns are preferred aesthetically by the general population.

The Ergonomic FALD Flap for One-stage Total Breast Reconstruction.

The fat-augmented latissimus dorsi (FALD) flap combines this pedicled flap with immediate intraoperative fat transfer. Very little is described concerning its inset at the mammary site. Our efforts have concentrated on seeking the best flap orientation and skin-adipose paddle shaping, to improve the aesthetic outcome and to obtain a complete breast reconstruction (BR) in one stage. A prospective clinical study was performed in patients who underwent BR with FALD flaps, between December 2020 and March 2022. Patients were randomly enrolled into two groups: ergonomic inset of the FALD flap with vertical orientation of the skin-adipose paddle (group A) and FALD flap with traditional horizontal paddle orientation (group B). The study's endpoints were the evaluation of the aesthetic outcomes (from patients' and surgeon's perspectives) and complications. Thirty-two FALD flaps (23 patients) were performed for group A, and 31 FALD flaps (25 patients) for group B. The two groups were homogeneous in terms of demographic and surgical data (P > 0.05). The overall complication rate was homogeneous among the groups, without statistically significant differences (P = 1.00). The surgeon's assessments showed a statistically significant superior aesthetic outcome in group A regarding volume, symmetry, and shape (P < 0.05). Higher satisfaction was observed in group A patients, in terms of breast size (P < 0.00001), shape (P = 0.0049), and overall satisfaction (P = 0.00061). The ergonomic vertical FALD flap technique enables surgeons to perform one-stage total BR, with excellent breast projection and upper pole fullness. These refinements in flap shaping and molding reduced the need for further autologous fat transfer, obtaining a brilliant totally autologous BR without the need for microsurgical experience.

Comparative evaluation using PRO of an algorithm of one-stage immediate alloplastic breast reconstruction versus two-stage reconstruction

One-stage direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique, but there are some conditions that do not allow its performance. The introduction of new surgical techniques and the recent COVID-19 pandemic have pushed us to introduce a breast reconstruction algorithm in our clinical practice. This allows a one-stage immediate reconstruction for all patients, regardless of their anatomical characteristics, the type of implants used, and the need for postoperative radiotherapy. A total of 40 patients were recruited and divided into two cohorts, 20 patients underwent immediate one-stage breast reconstruction in the period between October 2019 and January 2021, and 20 patients completed the two-stage reconstructive process in the period prior to October 2019. During the follow-up at 6 months, all patients who had completed the reconstructive process filled out the Breast-Q Reconstruction Module Pre and Postoperative scales questionnaire. The outcomes of the questionnaires were compared between the two cohorts, and statistical analysis was carried out using SPSS Statistics 20 (IBM Corporation, Armonk, NY, USA). The analysis of patient-reported outcomes showed that patients from the one-stage group reported better outcomes in all items evaluated. We did not find statistically significant differences concerning the rate of complications and length of hospital stay between the two groups. The analysis of the results shows that the outcomes reported by patients who completed breast reconstruction according to our algorithm are statistically better than those with the two-stage technique.

Total Breast Reconstruction with Lipofilling after Traditional Mastectomy without the Use of Tissue Expanders.

Lipofilling can be used to reconstruct a breast without additional implants or autologous composite grafts. However, methods to maximize retention of the transferred fat remain under debate. Here, the authors present their experience of breast reconstruction with lipofilling without concomitant use of tissue expanders. Patients who had completed breast reconstruction with lipofilling between June of 2010 and June of 2016 were reviewed. Those with obtainable follow-up magnetic resonance imaging scans were included in this cross-sectional study. The hospital records were reviewed for details of the lipofilling operations. Magnetic resonance imaging scans were evaluated for the volume retention and quality of the transferred fat. The patients were asked to assess the appearance and sensitivity of the reconstructed breast, the recovery time, and any adverse effects at the fat donor area. Thirty-eight women with 41 reconstructed breasts were included in the study. The median age at follow-up was 62 years (range, 48 to 78 years). They had undergone a median of four (range, two to six) lipofilling procedures with a median total volume 690 mL (range, 369 to 1350 mL). After a median follow-up of 2.1 years (range, 0.4 to 6.8 years), the median proportion of transferred fat retained was 58% (range, 14% to 119%), representing a reconstructed breast volume of 76% (range, 17% to 100%) of the contralateral breast. Oil cysts larger than 10 mm were detected in 7%. Most patients reported being satisfied with the reconstructed breast and experienced few side effects. Breast reconstruction with lipofilling can be performed with an acceptable number of procedures and no preoperative skin expansion. It extends the option of autologous breast reconstruction to women unsuited for major reconstructive procedures. Therapeutic, IV.

Breaking Barriers to Breast Reconstruction among Socioeconomically Disadvantaged Patients at a Large Safety-net Hospital.

Background:Socioeconomic disparities remain prevalent among those who undergo breast reconstruction. At our institution, patients must meet certain criteria to become eligible for breast reconstruction. The purpose of this study was to determine the impact of socioeconomic factors on breast reconstruction eligibility, enrollment, choice, and completion at our large safety-net institution.Methods:A retrospective chart review of patients who underwent partial or total mastectomy at a large safety-net hospital from 2016 to 2019 was completed. Surgical and demographic data were compared across varying socioeconomic factors.Results:A total of 645 patients were included in the study. More patients of a racial minority had government-based insurance than White patients (89% versus 81%; P = 0.01). Those with government-based insurance had higher average hemoglobin A1c values (6.26 versus 6.0; P = 0.03), proportion of American Society of Anesthesiologists scores greater than III (46% versus 40%; P = 0.01), and smokers (23% versus 9%; P = 0.02) than those with private insurance. Diabetic patients, patients with an American Society of Anesthesiologists greater than III, and active smokers were significantly less likely to receive a plastic surgery consult. Patients with government-based insurance underwent immediate tissue expander placement at mastectomy at rates lower than those with private insurance (57% versus 69%; P = 0.01).Conclusions:Barriers remain for socioeconomically disadvantaged patients to be eligible for, undergo, and complete breast reconstruction. Obesity, diabetes, smoking, and poor overall health were identified as the main barriers and were associated with racial minorities, government-based insurance, and lower incomes. Concerted effort through multidisciplinary teams is needed to maximize eligibility of socioeconomically disadvantaged breast cancer patients for reconstruction.

The effect of radiotherapy on fat engraftment for complete breast reconstruction using lipofilling only

PurposeLipofilling has been established as a standard technique for contour enhancement following breast reconstruction. However, there is a paucity in current literature regarding the use of this technique for complete reconstruction of the female breast as an alternative to conventional techniques, such as expander or flap-based procedures. In particular, the influence of pre-operative irradiation for successful reconstruction has rarely been examined in published studies. Here, the authors describe their experience with successful fat injection in pre-radiated breasts in comparison with non-pre-radiated patients.MethodsIn this retrospective study, we examined a total of 95 lipofilling treatments on 26 patients (28 breasts). All of them experienced mastectomy following breast cancer; local breast defects after partial resection of the gland were not included in this study. In total, 47 lipofilling procedures in 12 non-irradiated patients (14 breasts) and 48 procedures in 14 irradiated women (also 14 breasts) were performed. Per session, approximately 297 ± 112 cc of adipose tissue was grafted in group A (no radiotherapy) and approximately 259 ± 93 cc was grafted in group B (radiotherapy).ResultsAmong the group of women without pre-operative radiation, 71% of breast reconstructions limited to lipofilling only showed constant engraftment of fat tissue with a successful reconstructive result, whereas only 21% of the patients with pre-radiated breasts showed complete reconstruction of the breast with a permanent fat in-growth.ConclusionPreoperative radiotherapy significantly impedes successful completion of breast reconstructions planned only by autologous fat transfer. Patients should be selected individually and carefully for complete breast reconstruction using lipofilling only.

Association of Radiation Timing with Long-Term Satisfaction and Health-Related Quality of Life in Prosthetic Breast Reconstruction.

Radiation therapy is increasingly used after breast cancer surgery, which may impact patients' postoperative quality of life. This study assessed differences in long-term patient satisfaction and health-related quality of life after radiation therapy administered at different stages of implant-based breast reconstruction or with no radiation after surgery. In this observational study, long-term outcomes were evaluated for four cohorts of women who completed breast reconstruction and received (1) no radiation, (2) radiation before tissue expander placement, (3) radiation after tissue expander placement, or (4) radiation after permanent implant between 2010 and 2017 at Memorial Sloan Kettering. Satisfaction and health-related quality of life were assessed using the prospectively collected Satisfaction with Breasts and Physical Well-Being of Chest BREAST-Q subscales. Score distributions were examined by radiation exposure status for 3 years after surgery using nonparametric analyses and regression models. Of 2932 patients who met the inclusion criteria, 25.8 percent received radiation during breast cancer treatment, including before tissue expander placement ( n = 239; 8.2 percent), after tissue expander placement ( n = 290; 9.9 percent), and after implant placement ( n = 228; 7.8 percent). Radiotherapy patients had average scores 7 to 9 points lower at all postoperative time points for Satisfaction with Breasts and Physical Well-Being of Chest subscales ( p < 0.001). Although patient-reported outcomes did not differ by radiation timing, there were higher rates of severe capsular contracture with postimplant radiotherapy ( p < 0.001). Radiation therapy significantly affected patient satisfaction and health-related quality of life following implant breast reconstruction through 3 years postoperatively. Patient perception of outcome was unaffected by radiotherapy timing; however, capsular contracture was higher after postimplant radiotherapy, suggesting there may be an advantage to performing radiotherapy before placement of the final reconstruction. Therapeutic, III.

Body Self-Perception After Breast Reconstruction in Young Female Patients Affected by Poland Syndrome

BackgroundCosmetic and social aspects of breast anomalies in Poland syndrome are not negligible. Early diagnosis and appropriate therapeutic timing may have a positive impact on quality of life.MethodsFemales affected by Poland syndrome, who had breast reconstruction between 2014 and 2018, were asked to complete the Body Uneasiness Test and the postoperative Breast-Q. Correlation between scores was evaluated. Correlation between scores was statistically evaluated.ResultsThirty patients who had completed breast reconstruction at 20.9 ± 6.5 yo fulfilled the questionnaires at the average age of 26.5 ± 8.1 yo. BUT scores were similar to healthy population considering different age groups, with the exception of Compulsive Self-Monitoring subscale for 16–17-year age group. A correlation between Depersonalization and “Thighs” and “Legs” was present. On average, satisfaction with breast resulted 79.1%, satisfaction with surgical outcome was 94.9%, psychosocial well-being was 78.5%, sexual well-being was 75.3%, and relative physical well-being in chest and upper body was 36.9%. Global Uneasiness, Avoidance, Weight Phobia, Body Image Concern and Depersonalization were significantly correlated with lower psychosocial well-being. Avoidance was significantly correlated with lower sexual well-being.ConclusionsBreast reconstruction in Poland syndrome can help to improve quality of life. However, general body uneasiness can affect satisfaction with the final result.Level of Evidence IVThis 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 http://www.springer.com/00266.

Fat Grafting following Internal Tissue Expansion: An Option for Breast Reconstruction after Total Mastectomy.

Background:Breast reconstruction is currently performed as standard practice.Methods:A prospective study was performed of patients after total mastectomy who underwent autologous breast reconstruction with fat grafting (FG) combined with internal tissue expansion between September 2015 and December 2020. The patients were classified into groups A to F depending on the steps of breast reconstruction. Groups A and B described patients with completed breast reconstruction with FG and expander removal, with or without nipple/areola complex reconstruction. C described patients during deflation of the expander combined with simultaneous FG. D described patients after expander implantation and refilling. E described patients after first FG, and F included patients who discontinued reconstruction with the described method and converted to reconstruction with a breast implant.Results:Among 22 treated patients‚ two were after first FG (9.09%‚ group E), two were after expander implantation and refilling (9.09%‚ group D), three were during deflation of the expander combined with simultaneous FG (13.63%‚ group C), and four (18.18%) had completed breast reconstruction—two (9.09%) without NAC reconstruction and symmetrization (group B) and two (9.09%) with completed breast reconstruction (group A). In 11 patients (50%), breast reconstruction was abandoned after expander implantation and one to three FG procedures (group F), converting to breast reconstruction with a breast implant.Conclusions:This study demonstrated successful breast reconstruction using FG and expander implantation. Breast reconstruction using this method is safe and enables possible abandonment at any treatment stage, as well as conversion to breast reconstruction with implants.

Reverse Expansion Following Nipple Sparing Mastectomy: A Natural, Safe and Effective Autologous Technique for Breast Reconstruction.

The majority of surgeons choose an implant-based breast reconstruction after mastectomy. Nevertheless, lipofilling is a constantly growing technique allowing a complete breast reconstruction without prosthesis. We introduce our experience using reverse expansion for breast reconstruction following a nipple-sparing mastectomy (NSM) with a subpectoral skin expander. In the period January 2010-August 2021, 106 breast reconstruction procedures were performed on 50 patients after a NSM. We harvested an amount of fat tissue using a 2.5 mm liposuction cannula, we centrifuged it 3min at 4000 rpm and injected in the recipient site using 3 ml syringes and Coleman cannulas. At the beginning of every session, the breast expander was deflated of a saline volume similar to the one of the fat to be injected. We harvested an average of 679.2 ccs of fat per session and injected an average of 319.3 ccs per breast. The mean number of sessions has been 2.4 per breast. The average number of sessions in a radiotreated patients' subgroup has been slightly higher than a control group. The mean follow-up time was 63.5 months and we observed no complications in 105 over 106 procedures. Lipofilling has proven to be a safe and effective technique for complete breast reconstruction. Our procedure considers the use of a breast expander as a device to prepare the recipient site. Reverse expansion after a NSM allows a like-with-like reconstruction and it might be the first reconstructive choice in a selected group of patients.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 .

Breast Reconstruction: Does It Worth to Start If the Patient Is Not Sure to Take All the Process Along?

Introduction: Breast cancer is the most common cancer in women worldwide, representing a major public health problem. There is still little information comparing the satisfaction of the patients who finished their process against the ones who start it but did not finish it. The aim of our retrospective study was to analyze the results in terms of satisfaction after one year of undergoing to complete breast reconstruction (CBR) vs incomplete breast reconstruction (IBR). Materials and Methods: Retrospective study of patients that underwent breast reconstruction (BR) surgery after mastectomy for breast cancer treatment. Performed at Hospital Central Sur de Alta Especialidad PEMEX in Mexico City, including patients from January 1, 2015 to January 01, 2020. Demographic baseline variables were included. BREAST-Q satisfaction questionnaires one year after the last reconstructive procedure were analyzed. Results: A total of 44 patients fulfilled the inclusion criteria. Of these 44 patients, 11 were included in the IBR group, and 33 patients in the CBR group. There were no statistically significant differences between the two groups in terms of age (IBR 56.09 vs CBR 53.06 years, p = 0.321); BMI (IBR 27.94 vs CBR 26.40, p = 0.253), time from mastectomy to first reconstructive procedure (IBR 22.8 vs CBR 31 months, p = 0.957), history of chemotherapy (IBR 27.3% vs CBR 33.3%, p = 0.709) and radiotherapy (IBR 54.5% vs CBR 42.4%, p = 0.484), additionally type of reconstruction, affected side or complication rate were not significantly different. Regarding postoperative satisfaction, only the second module of satisfaction with breasts displayed statistically significant differences, with a higher score in the CBR group (46.27 vs 52.27, p = 0.019). Other items explored didn’t show significant differences. Discussion: The data reported in this study suggest that regardless of whether the last stage of a BR is reached, the results in these settings can be very similar in terms of psychosocial well-being, sexual well-being, physical well-being regarding the chest area, with some degree of better perception of her breasts. Conclusion: This study suggests that the results in terms of satisfaction in BR after mastectomy for breast cancer are quite similar for patients who decide to take only the first reconstructive stage, compared with those that finished all the process along, this may be a valuable tool for decision making.

Carbon Dioxide based versus Saline Tissue Expansion for Breast Reconstruction; A Meta-Analysis

Introduction: Radical mastectomy shall be a lifesaving procedure for patients with breast cancer. However, it is associated with considerable alteration of patients’ self-esteem and body image. Currently, 40% of women are subjected to breast reconstruction subsequent to radical mastectomy, ranking such surgery the most common reconstruction approach. Two-stage tissue expander-to-implant is the preferable technique that accomplished the desired aesthetic outcomes. The current study was executed to assess the safety and efficacy of Carbon-dioxide based tissue expansion, in contrast to saline-based tissue expansion. Materials and Methods: Comprehensive literature review up to 1 December 2020 was carried out throughout the following databases; PubMed, Google Scholar, Web of Science, Scopus, WHO Global Health Library, Clinical trials, Cochrane, SIGLE, NYAM, mRCT, and ICTRP to identify all clinical studies compared carbon-dioxide based and saline-based tissue expansion. Data analysis was done using Review Manager version 5.3 (RevMan5.3). The significant difference was established at P &lt; 0.05. Results: This meta-analysis included four articles which comprised 619 reconstructed breasts. Of them, 374 breasts were reconstructed using carbon-dioxide based tissue expander, whereby 245 breasts were reconstructed using saline-based tissue expander. Carbon-dioxide based tissue expander accomplished statistically significant shorter duration to accomplish complete expansion (MD-36.28;95%CI-44.09,-28.47; P&lt;0.001) and shorter duration to achieve complete reconstruction (MD-41.91;95%CI-54.24,-29.58; P&lt;0.001). There was no statistically significant difference between carbon-dioxide and saline-based tissue expanders regarding the success rate (RR 1;95%CI 0.96, 1.06; P=0.85), device malfunction (RR 0.94;95%CI 0.11, 8.06; P=0.96), and implant extrusion (RR 0.71;95%CI 0.14, 3.62; P=0.68). There was no statistically significant difference between both methods regarding total; complications (RR 0.93;95%CI 0.64, 1.37; P=0.72). This includes wound infection (RR 0.46;95%CI 0.08, 2.72; P=0.39), wound dehiscence (RR 0.47;95%CI 0.10, 2.25; P=0.34), seroma (RR 1.01;95%CI 0.40, 2.57; P=0.99), and hematoma (RR 0.28;95%CI 0.06, 1.29; P=0.1). Conclusions: Carbon-dioxide based tissue expander is a safe, effective, and promising approach with considerable advancement relative to saline-based tissue expander, principally regarding the time to accomplish complete implant expansion and the time to achieve complete breast reconstruction.

Efficacy of an external volume expansion device and autologous fat grafting for breast reconstruction following breast conserving surgery and total mastectomy: Small improvements in quality of life found in a prospective cohort study

Although autologous fat grafting (AFG) for breast reconstruction is feasible, the best methods have yet to be established. This study aimed to assess the efficacy of fat grafting using an external expansion device for complete breast reconstruction post breast cancer surgery hypothesizing that it would improve quality of life. A prospective cohort study was conducted in women who had undergone breast cancer surgery and complete reconstruction using AFG. An external expansion device was used previously (as per Miami protocol) to a single-stage AFG. Quality of life outcomes were determined using the validated BREAST-Q questionnaire, and 3D laser and magnetic resonance imaging scan were used to measure fat graft retention. Twenty-six participants were recruited, with seven withdrawing. The remaining 19 women were compliant with external expander use. The mean volume of AFG was 270.4 mL (98-490 mL) with a mean of 48.8% retained at 12 months following injection. Symmetry improved but did not meet the acceptable symmetry ratio of 0.8. Nine patients (47.3%) noted increased skin elasticity and softening of areas of scarring. Skin irritation occurred in 11 out of 19 patients. Mean BREAST-Q scores improved significantly in the domains of satisfaction with breast (40 vs. 49, p< 0.001), psychosocial well-being (55 vs. 68, p<0.001), physical well-being abdomen (73 vs. 87, p<0.001), and sexual well-being (41 vs, 48, p<0.001). Improved quality of life and breast volume increase were achieved following external expansion and AFG. However, breast fat engraftment retention was similar to that reported in previous studies using fat grafting alone.

Influence of vascularized lymph node transfer (VLNT) flap positioning on the response to breast cancer-related lymphedema treatment.

to evaluate the initial therapeutic experience of transplantation of vascularized lymph nodes in patients with lymphedema of the upper limbs secondary to the treatment of breast cancer, and to verify if the positioning of the transplant influences the surgical result. we conducted a prospective, comparative test of two therapeutic modalities, with 24 patients with lymphedema of the upper limb after breast cancer treatment, classified as grades 2 and 3, according to the International Lymphedema Society. The two types of procedures performed were: 1) total breast reconstruction with - deep inferior epigastric perforator (DIEP) flap associated with lymph node flap, in patients with no previous breast reconstruction or loss of previous reconstruction (axillary positioning); 2) isolated inguinal lymph node flap performed in patients with completed breast reconstruction or without the desire to perform the breast reconstruction (wrist positioning). the reduction percentage of the affected limb volume was 20.1% (p=0.0370). The number of infectious episodes (cellulites) also decreased significantly, from 41% in the preoperative period to 12.5% in the postoperative one (p=0.004). There were no differences between the proximal and distal groups. the transplantation of lymph nodes positively affected the postoperative evolution of patients with lymphedema secondary to breast cancer. We observed no differences in relation to flap positioning.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL): a collaborative effort for diagnosis and treatment

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a very uncommon disease that has only recently appeared in the literature. Based on data from medical literature reports, the US Food and Drug Administration (FDA) estimates the lifetime risk of this distinct cancer to be between 1 in 3,817 to 1 in 30,000 in patients with textured breast implants. Due to the high incidence of breast implantation for both cosmetic and reconstructive reasons, it is important that general surgeons are aware of this clinical entity so that they will involve their plastic surgeon colleagues early in the management of this cancer. Our patient is a 37-year-old female who presented to an outpatient plastic surgery clinic in 2008 with fluctuation in the size of her left breast 16 years after cosmetic bilateral augmentation mammoplasty with saline Biocell textured implants. Initial suspicion for seroma was managed by surgical drainage with pathologic investigation showing atypical cells with high nucleus to cytoplasm ratio. Symptoms appeared to resolve following drainage until the patient discovered a mass in the same breast 7 years later. After immunohistochemical (IHC) staining of the excised specimen demonstrated positivity for CD30 with negative ALK-1, lymphoma was suspected, and surgical oncology was involved in management. PET/CT imaging demonstrated localized disease and isolated surgical management was recommended for our patient. Excision of the left breast capsule with removal of left breast implant was performed and pathology showed features characteristic for a T-cell anaplastic large cell lymphoma (T-ALCL). Shortly thereafter, local recurrence was evident requiring mastectomy, capsulectomy, and chemotherapy. The patient has since completed breast reconstruction and is currently in remission from BIA-ALCL. There are many areas of further investigation required to reduce morbidity in treatment of this disease. In the early period of investigation into this new unique cancer diagnosis, it is important to utilize a comprehensive team approach to collaborate on the optimal treatment for each patient with the diagnosis of BIA-ALCL.

Does 2-Stage Implant-Based Breast Reconstruction Allow for a Larger Volume of the Definite Implant Compared With 1-Stage Reconstruction?

Breast reconstruction using implants is still the main breast reconstruction technique worldwide. Current debate within implant-based breast reconstruction is whether to perform a 1-stage (direct implant) or 2-stage (tissue expander/implant) reconstruction. Volume differences between a woman's native breast and changes in volume after breast reconstruction might be an important factor for a patient's choice between these types of reconstruction. Three-dimensional imaging facilitates objective breast volume estimates. The goal of this study was to investigate differences between the patient's natural breast and the volume after completed breast reconstruction. One- and two-stage implant-based breast reconstruction techniques were compared. Finally, it was assessed whether patient satisfaction is causally related with the final breast volume after reconstruction. A total of 38 patients were included in the study, including 35 two-stage breast reconstructions and 27 one-stage reconstructions. Preoperative and postoperative 3-dimensional images of the breast with the Vectra XT Imaging system were taken. Volume analysis was performed to estimate the patient's native breast volume. Implant size were derived from the operation report. A mean volume reduction for the 1-stage reconstruction group was found -1 mL, whereas an increase of +80 mL was found in the 2-stage reconstruction group (P < 0.005). Patient satisfaction related to volume outcome was not significantly different between both groups, using the Breast-Q questionnaire. This study shows that a 2-stage breast reconstruction has the potential of an increased breast volume compared with a similar breast volume in 1-stage reconstruction.

A Breast Reconstruction Using a Breast Prosthesis and Capsular Flap for a Lymphocele Patient.

Summary:We encountered a very rare condition where the patient had a lymphocele under the skin envelope of the breast following mastectomy during the course of breast reconstruction with a tissue expander. The incidence rate of axillary lymphoceles is reported as 2.2–50% in breast cancer patients, but there have been no reports mentioning lymphoceles under the breast skin during the course of breast reconstruction with a prosthesis. The patient had a lymphocele in the lower lateral part of the breast following mastectomy and had multiple cellulitis-like inflammations. These inflammations were treated with conservative therapy such as administration of antibiotics, resting, and cooling. After 6 months of the initial surgery, the patient underwent complete resection of the lymphocele, preventative elimination of a possible lymphatic leakage, and breast reconstruction using a prosthesis combined with a capsular flap. The capsular flap is a transposition flap that uses capsular tissue around the expander to cover adjacent thinned skin. There were no postoperative complications such as breast skin necrosis, exposure of the prosthesis, or recurrence of the lymphocele and cellulitis. The patient had a successful breast reconstruction even though a lymphocele of the breast was observed. Even though a patient may have a lymphocele in the breast following mastectomy, with careful resection of the lymphocele, complete elimination of possible lymphatic leakage, and by performing the capsular flap technique, complete breast reconstruction with a breast prosthesis may be successful.

‘Reverse expansion’: A new technique of breast reconstruction with autologous tissue

The treatment for breast cancer is sometimes long and requires a multidisciplinary approach. In 2010, in our centre, we began to perform fat grafting for breast reconstruction using the so-called 'reverse expansion' technique. This consists of the insertion of a skin expander during mastectomy, in its expansion and then in its gradual deflation in the surgical theatre during fat grafting. We performed a complete breast reconstruction in 57 patients by reverse expansion. We harvested fat from the fat excess areas using a normal liposuction cannula. From each patient, an average of 640ccs of was collected and then centrifuged in a 4000-rpm centrifuge for 3min. The obtained adipocytes were then injected in the operated breast using a normal lipofilling cannula. We injected an average of 318.05ccs of adipocytes for each patient each time. The average number of sessions per patient was 3.6. Reverse expansion can be a safe and effective technique for breast reconstruction in all the breast cancer patients.

Abstract: Implant Reconstruction Does Not Require Any More Procedures than Autologous Reconstruction for Completion

INTRODUCTION: Breast reconstruction may require multiple procedures beyond the initial surgery. Estimates range from 2 1,2 to 6 3 procedures required. The reconstructive course may stretch over months and even years.4 Previous studies of the number of procedures and amount of time required to complete breast reconstruction have been limited in the factors considered and have reached conflicting conclusions. The authors aimed to determine the number of procedures and length of time it took a large, diverse, population of women to complete breast reconstruction. METHODS: Women undergoing breast reconstruction since 2003 with follow up in our institution’s medical record system were reviewed. Reconstruction completion was defined by the last procedure a patient underwent, even if she did not undergo nipple/areolar reconstruction. Chisquared and independent t-tests were used to identify variables associated with number of procedures and length of time required for reconstruction. Significantly associated (p<0.05) variables were used in regression analysis. RESULTS: Four hundred thirty three patients were included. Seventy-five patients with procedures pending at the end of follow-up were excluded. Patients underwent an average of 4.06 ± 1.95 procedures (range 2–12) over 593 ± 648 days. Marital status, ethnicity, occupational status, axillary dissection, radiation, chemotherapy, laterality, and reconstruction type were not associated with either number of procedures or length of time required. In a linear regression predicting time required for reconstruction, higher BMI was associated with shorter time requiredfor reconstruction (16.5 days per unit BMI increase, p=0.006) and undergoing nipple reconstruction or tattooing was associated with increased time (287 days extra, p<0.0001). In a linear regression predicting number of procedures required for reconstruction, undergoing nipple or areola reconstruction (p<0.0001), dehiscence (p=0.033), seroma (p=0.030), implant exposure (p=0.001), hematoma (p<0.0001), partial flap loss (p<0.0001), implant infection (p<0.0001), and number of complications (p<0.0001) positively predicted increased number of operations. Nipple reconstruction or tattooing and partial flap loss were the strongest predictors, with 1.92 and 2.67 additional procedures associated with each respectively. CONCLUSIONS: The patients in this study underwent a number of procedures falling between previous estimates. As expected, complications and nipple reconstruction/tattooing were associated with increased numbers of procedures. Eom et al. found that expander-implant reconstruction patients underwent more procedures than autologous reconstructions while Losken et al. found the reverse – in the present cohort, no difference between reconstruction types was found.2,3 Similarly, radiation exposure and chemotherapy were not associated with increased number of procedures as reported elsewhere.2 The current findings reinforce that breast reconstruction may be a prolonged and arduous process. REFERENCES: 1 Damen TH, Mureau MA, Timman R, Rakhorst HA, Hofer SO. The pleasing end result after DIEP flap breast reconstruction: A review of additional procedures. J Plast Reconstr Aesthet Surg. 2009;62:71–76. doi:10.1016/j.bjps.2007.09.045. 2 Eom JS, Kobayashi MR, Paydar K, Wirth GA, Evans GRD. The number of operations required for completing breast reconstruction. Plast Reconstr Surg Glob Open. 2014;2:e424. doi: 10.1097/GOX.0000000000000111 3 Losken A, Carlson GW, Schoemann MB, Jones GE, Culbertson JH, Hester TR. Factors that influence the completion of breast reconstruction. Ann Plast Surg. 2004;52:258–262. doi:10.1097/01.sap.0000110560.03010.7c 4 Losken A, Duggal CS, Desai KA, McCullough MC, Gruszynski MA, Carlson GW. Time to completion of nipple reconstruction: What factors are involved? Ann Plast Surg. 2013;70:530–532. doi:10.1097/SAP.0b013e318281ac61