Oncologic Mastectomy Research Articles

Flat Aesthetic Mastectomy Closure with the Angel Wing Technique to Address Lateral Adiposity: Technique and Outcome Analysis

Introduction. Oncologic mastectomy in the setting of obesity poses challenges in achieving a flat closure that includes the lateral adiposity. The angel wing (AW) technique was developed to address this issue. We aim to demonstrate the safety of AW by evaluating incidence of arm lymphedema (AL) and decreased range of motion (dROM) in patients postmastectomy with and without the AW closure. Methods. We performed a single-center retrospective cohort study at an academic referral center of patients who underwent mastectomy with and without the AW technique from May 2014 to October 2022. Those who received breast reconstruction (immediate or delayed), partial mastectomy, and male patients were excluded. The presence of postoperative AL and dROM was evaluated. Subgroup analysis was performed for patient factors including BMI, extent of axillary surgery, PMRT, and pathologic stage. Results. A total of 390 patients met inclusion criteria. Of those, 173 (44.4%) underwent AW and 217 (55.6%) had non-AW mastectomy. Expectedly, the average BMI was significantly higher in the AW cohort (p<0.0001). The overall rate of AL was 51/390 (13.1%), seen in 27 (15.6%) undergoing AW and 24 (11.1%) non-AW (p value = 0.18). While the rate of dROM within the cohort was 52/390 (13.1%), 27 (15.6%) underwent AW vs. 24 (11.1%) non-AW (p value = 0.22), resulting in no statistical significance between AW and non-AW mastectomy upon subsequent development of AL or dROM. Conclusion. Our study demonstrates the AW technique does not convey an increased risk of overall AL or dROM, even when considering known risk factors such as obesity, PMRT, and extent of axillary surgery. As we strive to provide our patients with improved surgical techniques for oncologic resection, we submit that this technique is a viable and safe option for achieving the goals of cosmesis with oncologic safety.

Reviewing the Impact of Topical and Intravenous Tranexamic Acid Use in Breast Plastic Surgery.

Topical and intravenous uses of tranexamic acid (TXA) have been shown to reduce bleeding and ecchymosis in various surgical fields. However, there is a lack of data evaluating the efficacy of TXA in breast surgery. This systematic review evaluates the impact of TXA on hematoma and seroma incidence in breast plastic surgery. A systematic review of the literature was performed for all studies that evaluated the use of TXA in breast surgery including reduction mammoplasty, gynecomastia surgery, masculinizing chest surgery, or mastectomy. Outcomes of interest included rate of hematoma, seroma, and drain output. Thirteen studies met the inclusion criteria with a total of 3297 breasts, of which 1656 were treated with any TXA, 745 with topical TXA, and 1641 were controls. There was a statistically significant decrease in hematoma formation seen in patients who received any form of TXA compared with control (odds ratio [OR], 0.37; P < 0.001), and a similar tendency toward decreased hematoma with topically treated TXA (OR, 0.42; P = 0.06). There was no significant difference in seroma formation with any TXA (OR, 0.84; P = 0.33) or topical TXA (OR, 0.91; P = 0.70). When stratified by surgery, there was a 75% decrease in the odds of hematoma formation with any TXA compared with the control for oncologic mastectomy (OR, 0.25; P = 0.003) and a 56% decrease in nononcologic breast surgery (OR, 0.44; P = 0.003). This review suggests that TXA may significantly reduce hematoma formation in breast surgery and may also decrease seroma and drain output. Future high-quality prospective studies are required to evaluate the utility of topical and intravenous TXA in decreasing hematoma, seroma, and drain output in breast surgery patients.

Novel nomograms for predicting survival for immediate breast reconstruction patients diagnosed with invasive breast cancer-a single-center 15-year experience.

Immediate breast reconstruction is widely accepted following oncologic mastectomy. This study aimed to build a novel nomogram predicting the survival outcome for Chinese patients undergoing immediate reconstruction following mastectomy for invasive breast cancer. A retrospective review of all patients undergoing immediate reconstruction following treatment for invasive breast cancer was performed from May 2001 to March 2016. Eligible patients were assigned to a training set or a validation set. Univariate and multivariate Cox proportional hazard regression models were used to select associate variables. Two nomograms were developed based on the training cohort for breast cancer-specific survival (BCSS) and disease-free survival (DFS). Internal and external validations were performed, and the C-index and calibration plots were generated to evaluate the performance (discrimination and accuracy) of the models. The 10-year estimated BCSS and DFS were 90.80% (95% CI: 87.30%-94.40%) and 78.40% (95% CI: 72.50%-84.70%), respectively, in the training cohort. In the validation cohort, they were and 85.60% (95% CI, 75.90%-96.50%) and 84.10% (95% CI, 77.80%-90.90%), respectively. Ten independent factors were used to build a nomogram for prediction of 1-, 5- and 10-year BCSS, while nine were used for DFS. The C-index was 0.841 for BCSS and 0.737 for DFS in internal validation, and the C-index was 0.782 for BCSS and 0.700 for DFS in external validation. The calibration curve for both BCSS and DFS demonstrated acceptable agreement between the predicted and actual observation in the training and the validation cohorts. The nomograms provided valuable visualization of factors predicting BCSS and DFS in invasive breast cancer patients with immediate breast reconstruction. The nomograms may have tremendous potential in guiding individualized decision-making for physicians and patients in choosing the optimized treatment methods.

Oncological Mastectomy in the Context of Reaffirmation of Sex in a Male Transgender Patient: Case Report and Literature Review

Background: Breast cancer in the male transgender patient is a great challenge for the medical team, because it is completely different from the usual clinical scenario and there is a lack of scientific knowledge and protocols for managing this special medical situation. Case presentation: We present a 32-year-old transmasculine patient, who developed a palpable nodule on the left breast during the androgen hormonal treatment. Imaging showed a BIRADS5 nodule and core biopsy detected a luminal B breast invasive carcinoma (IDC) with androgen receptor expression. He underwent a gender reaffirmation oncological mastectomy, chemotherapy and hormonal therapy. Conclusion: In the transgender male scenario, the surgical technique should take into consideration the patient’s aesthetical desire and the oncological result. In this context, it is controversial if the hormonal and oncological therapies should also be changed.

Gender-affirming Mastectomy with Concurrent Oncologic Mastectomy.

Background:Transmasculine individuals may not have undergone gender-affirming mastectomy and retain natal breast tissue. Our center offers simultaneous oncologic mastectomy with gender-affirming reconstruction to patients who are diagnosed with breast cancer. This study is the first reported series of concurrent gender-affirming and oncologic mastectomies.Methods:A retrospective chart review of all patients undergoing gender-affirming mastectomy at a single institution from February 2017 to October 2021 was performed. Patients were included who had breast cancer diagnoses or pathologic lesions preoperatively. Demographic factors, comorbidities, surgical details, and oncologic history were collected. Both plastic surgery and breast surgery were present for the gender-affirming oncologic mastectomies.Results:Five patients were identified who presented for gender-affirming mastectomy in the context of breast pathologies. Average patient age was 50.2 ± 14.8 years, and no patients used testosterone at any time. Two (40%) patients had a prior breast surgery that included a breast reduction in one patient and breast conserving lumpectomies in another. Sentinel lymph node biopsies were performed in all patients. Only one patient had a positive sentinel lymph node and was subsequently referred for postoperative radiation and chemotherapy. No oncologic recurrence has been detected with 20.6 and 10.0 months of mean and median follow-up.Conclusions:When performed in a multidisciplinary and collaborative setting with breast surgeons and plastic surgeons, oncologic mastectomy can be performed safely while concurrently offering patients an aesthetic gender-affirming reconstructive outcome.

“Just Pulse it!” Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review

Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability.In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.

Abstract PS1-61: Clinical and patient reported outcomes in oncoplastic breast conservation surgery from a single surgeon's practice in a busy community hospital in Canada

Abstract Introduction: Oncoplastic breast surgery combines oncologic partial mastectomy with ipsilateral defect repair using volume displacement and volume replacement techniques with contralateral symmetrising surgery as appropriate. Oncoplastic surgery aims to maintain quality of life by pre-empting and mitigating against breast asymmetry whilst not compromising oncological effectiveness. Although growing in popularity in North America, many patients still do not have access to these techniques which usually involve longer operation times and require a surgeon with specialized oncoplastic training. This study demonstrates the implementation of an effective oncoplastic surgical practice in a community hospital within Canada and shows low rates of peri-operative complications as well as high levels of patient-reported outcome measures. Methods:A retrospective chart review of consecutive patients diagnosed with Stage 0-3 breast cancer treated with level I and level II oncoplastic techniques by a single breast surgeon was undertaken. Patient demographics, tumor characteristics, procedure types, and clinical outcomes were collected. Patient satisfaction was assessed with the Breast-Q questionnaire administered pre-operatively as well as 3 months and 9 months post-operatively. Results:Oncoplastic breast conservation surgery was performed in 340 patients over a 31 month period from 2017-2019. The average size of breast lesion was 1.8 cm with 96 patients having lesions 2-5 cm in size, and 10 patients having tumours &amp;gt;5cm. Thirty (8.8%) patients experienced a complication requiring intervention. Margin revisions were required in 21.8% of patients which reduced to 18% after the implementation of the new margin consensus guidelines. The completion mastectomy rate was 4.7%. Contralateral symmetrizing procedures were performed in 31 (9.1%) of patients by the surgeon performing the patient's breast conservation surgery. Breast Q scores increased across breast satisfaction, process of care, psychosocial, physical, and sexual satisfaction domains post-operatively. Conclusion:This study demonstrates the feasibility of an oncoplastic breast surgery practice in a busy community hospital in Canada. This adds to the growing body of North American data on the clinical and oncological safety of these techniques and introduces the idea of collecting patient-reported outcome measures within a Canadian population. We hope that this will serve to aid in the recruitment of oncoplastic-trained surgeons to both teaching and community hospitals and enable these techniques to become the standard of care in North America. Citation Format: Ashley DiPasquale, Zofia Prus-Czarnecka, Lindsay Delmar, Lashan Peiris. Clinical and patient reported outcomes in oncoplastic breast conservation surgery from a single surgeon's practice in a busy community hospital in Canada [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-61.

Low Risk of Persistent Pain, Sensory Disturbances, and Complications Following Mastectomy After Gender-Affirming Surgery.

Purpose: In recent years, there has been a significant increase in referrals for gender-affirming surgery to departments of plastic surgery in Denmark. There is currently no literature on postsurgical pain in trans men after mastectomy. We aimed at investigating the prevalence and severity of postsurgical persistent pain, sensory disturbances, and complications in trans men after mastectomy. Methods: The 90 trans men who underwent bilateral mastectomy between September 1, 2013 and August 31, 2018 were included. Patients' files were evaluated for complications, and 84 (response rate 93.3%) patients answered a questionnaire (validated for women undergoing oncologic mastectomy) regarding persistent pain and sensory disturbances. Results: Twenty-three patients (27.4%) reported either unilateral or bilateral persistent pain after mastectomy. Of these, 14 (60.9%) patients categorized the pain as mild. However, 77 (95.2%) of the patients did not use analgesics and nonopioid pain medication was sufficient for the remainder. Sensory disturbances were found in 44 (47.5%) of the patients, and 4 (4.8%) patients reported clear signs of neuropathic pain. Seven (7.8%) patients developed hematomas, and areola necrosis was seen in four (4.4%) patients. Due to infection, seven (7.8%) patients received antibiotics. Conclusion: Mastectomy as a part of gender-affirming surgery is a safe procedure with a few, nonsevere, complications. Although a quarter of the patients experienced persistent pain, the majority of that pain is mild, intermittent and can be treated with nonopioid pain medication.

Pectoral Fascia Preservation in Oncological Mastectomy to Reduce Complications and Improve Reconstructions: A Systematic Review.

Background:Excision of the pectoral fascia (PF) is routinely performed in oncological mastectomies. Preservation of the PF may, however, decrease postoperative complication rates for bleeding, infections, and seroma. It may also improve reconstructive outcomes by better prosthesis coverage, thereby reducing implant extrusion rates and improving cosmetic outcomes.Methods:A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis principles was performed. Studies describing PF preservation were searched in 3 databases. All studies including more than 10 patients were included. The main outcomes were oncological safety (local recurrence, regional and distant metastases, and mortality rates), complication rates (bleeding, infections, seroma), loss of the prosthesis after reconstructive surgery, and cosmetic outcomes following reconstruction.Results:Five studies were included. Three reported on 2 different randomized controlled trials (n = 73, and n = 244), and 2 studies were retrospective case series (n = 203 and n = 256). PF preservation did not affect oncological outcomes in terms of local recurrences, regional and distant metastases, or mortality rates. One study described a significantly lower incidence of seroma in the PF preservation group. No differences were found for bleeding complications and infections. No objective data were provided for reconstructive complications or cosmetic outcomes.Conclusions:The literature on PF preservation is scarce. Based on the current evidence, PF preservation seems oncologically safe while potentially reducing postoperative complication rates. It is expected that reconstructive outcomes will benefit from PF preservation, but these studies lack evidence on this topic. Future studies should provide insight into all aspects of PF preservation.

Opioid Consumption After Gender-Affirming Mastectomy and Two Other Breast Surgeries

BackgroundThere are few studies that evaluate patient-reported opioid consumption after discharge from surgery. In addition, there has been a call for “special care in prescribing opioids” for lesbian, gay, bisexual, transgender, questioning patients. Here, we evaluate if patients undergoing gender-affirming mastectomy (GAM) require different amounts of opioids for pain management after discharge compared alongside two surgeries with similar surgical exposure. Materials and methodsFrom October 2017 to July 2018, patients undergoing oncologic mastectomy without reconstruction, mammoplasty reduction, or gender-affirming mastectomy at a single institution were enrolled in a phone survey study to quantify opioids consumed after discharge from surgery. Patient information was captured from the medical record. A total of 170 patients were called between 14 and 30 d after discharge and were asked to count unused pills from their opioid prescription. ResultsA total of 99 patients participated and provided pill counts. There were differences between prescribed and consumed opioids within each surgery. Patients who underwent oncologic mastectomy were prescribed and consumed the lowest amounts of opioids. There were significantly more opioids prescribed to patients with GAM than mammoplasty reduction, but consumption was not statistically different. Patients with oncologic mastectomy, mammoplasty reduction, and GAM consumed a median of 0, 10, and 15 five mg oxycodone equivalent tablets, respectively. ConclusionsDespite similar approaches, surgeries had different opioid prescribing and use profiles. Generally, all patients were overprescribed opioids. Overprescribing may be especially problematic in patients with known higher risk of misuse and substance abuse. Granular data on patient consumption, demographics, and preoperative risk factors for opioid misuse may improve prescribing practices.

Inferior mammary fold reconstruction in reconstructed breast: a novel technique

Background: In breast reconstructive surgery, the infra-mammary fold (IMF) is an integral component of breast identity. The distortion of the IMF during breast surgery or reconstruction following mastectomy often requires restoration. We have developed a new IMF reconstruction technique using de-epithelialised dermis secured to the periosteum of the rib. This acts as a hammock to support the breast tissue in the new position. This paper presents our nine-year experience of performing this original technique following free tissue transfer or tissue expanders (TEs) to reconstruct the breast post-mastectomy. Methods: Pre-operatively, the new IMF line is marked out while the patient is in a standing position. Two centimeters of the lower border of the reconstructed breast is de-epithelialised. The pectoralis major fascia is accessed through the dermis and the lower third of the flap is raised and folded in upwards. The dermis is then stitched to the periosteum of the rib at the desired higher level using interrupted 2/0 polydioxanone (PDS) sutures; thus, creating the new IMF. Results: A total of 9 patients were included in this report. The average age was 49 years (range, 31–61 years). Two cases had bilateral subcutaneous mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction. One case had immediate DIEP on one side and delayed DIEP on the other. One case had bilateral delayed DIEP. Two cases had unilateral delayed DIEP reconstruction following oncological mastectomy. Three cases were following TEs in unilateral breast reconstruction one of which had a high IMF that needed lowering. IMF in all cases was recreated using the same technique; each achieving a satisfactory outcome with no complications recorded. Conclusions: This technique provides the reconstructed breast with a well-defined IMF and improves its projection. The results are long-lasting and provide a sharp breast-thoracic angle, which is fundamental in the creation of a natural-looking reconstructed breast.

Intraoperative Indocyanine Green Angiography for Fat Necrosis Reduction in the Deep Inferior Epigastric Perforator (DIEP) Flap

Fat necrosis is a frequent complication (up to 62.5%) of microsurgical breast reconstruction using the deep inferior epigastric perforator (DIEP) flap. This could have important clinical and psychological repercussions, deteriorating the results and increasing reconstruction costs. The aim of this study was to demonstrate the intraoperative use of indocyanine green angiography (ICGA) to reduce fat necrosis in DIEP flap. Sixty-one patients who underwent unilateral DIEP flap procedures for breast reconstruction after oncological mastectomy were included (24 cases with intraoperative use of ICGA during surgery, 37 cases in the control group). The follow-up period was 1 year after surgery. The association between the use of ICGA and the incidence of fat necrosis in the first postoperative year, differences in fat necrosis grade (I-V), differences in fat necrosis requiring reoperation, quality of life, and patient satisfaction were analyzed. The incidence of fat necrosis was reduced from 59.5% (control group) to 29% (ICG-group) (P = 0.021) (relative risk = 0.49 [95% CI, 0.25-0.97]). The major difference was in grade II (27% vs 2.7%, P = 0.038). The number of second surgeries for fat necrosis treatment was also reduced (45.9% vs 20.8%, P = 0.046). The ICG group had higher scores on the BREAST-Q. Intraoperative ICGA is a useful technique for reconstructive microsurgery that might improve patient satisfaction and reduce the incidence of fat necrosis by half as well as reduce its grade, especially in small fat necrosis cases; consequently, ICGA could reduce the number of secondary surgeries for treatment of fat necrosis.

Donor-site morbidities in 615 patients after breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap: a single surgeon experience

Transverse rectus abdominis myocutaneous flap is one of the most commonly used reconstruction tools after oncological mastectomy. However, post-operative donor-site morbidities remain an issue to be addressed. In this study, we retrospectively reviewed patients with either immediate or delayed breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap only, performed by a single surgeon, regarding the donor-site morbidity. From January 2012 to July 2017, the study subjects summed up to 615 patients, in a single institution. Preoperative planning and actual surgical techniques were outlined including the evaluation of the location of the perforators using a three-dimensional abdominal computed tomography angiography scan, minimal fascia sacrifice, beveled dissection and minimization of the tension on the central abdomen during closure. During a 1-year follow-up, a total of 33 patients (5.4%) were complicated with any donor-site morbidity. Those in need of secondary revision on their donor-sites accounted for 23 patients (69.7%). No factor was found statistically significant to increase the risk of donor-site morbidity. Many surgical techniques have been devised for closure of the donor-site in transverse rectus abdominis myocutaneous flap patients. And, several factors have been proposed as increasing the risk of donor-site morbidity. Although all the suggested predictive factors failed to prove its significance on increasing the risk, a set of preoperative planning and surgical techniques employed in our study has proven to be both safe and efficient in lowering the postoperative donor-site morbidities.

Non-intubated thoracic epidural anesthesia for modified radical mastectomy as an alternative to general anaesthesia

Purpose : We provide the application of modified radial mastectomy in perioperative treatment under awake thoracic epidural block in breast cancer operations. Methods : Twelve women who underwent modified radical mastectomy in elective breast cancer surgery were included in the study. All patients were treated without tracheal intubation using thoracic epidural anesthesia and sedation. The epidural catheter was placed in the T 4-5 level and the mixture of 0.5% bupivacaine and fentanyl was gradually administered with careful haemodynamic monitoring. Target-controlled propofol infusion was used. Pain intensity was evaluated by using a 10 cm VAS, where zero represented no pain and 10 cm represented worst possible pain. The primary endpoint was pain. A VAS score of 4 cm or less was considered to be an acceptable level of pain. The sedation situation was focused and calm in Wilson 2 level and in cooperation with sedation. Preoperative comorbidity and perioperative therapy were recorded. Results : We observed 4 hypotensive patients treated by increasing intravenous fluid infusion rate and initiating dopamine infusion. One patient had bradycardia, one patient had nausea and three patients had vomiting. There were no respiratory complications or pruritus. The mean duration of hospitalization is 5 days postoperatively. The patient had no intraoperative or postoperative complications. Conclusion : Epidural block in axillary lymph node dissection and oncologic mastectomy may be considered as a safe anesthetic option.

A 3-Dimensional Biomimetic Platform to Interrogate the Safety of Autologous Fat Transfer in the Setting of Breast Cancer.

Obesity is a known risk factor for the development and prognosis of breast cancer. Adipocytes have been identified as a source of exogenous lipids in other cancer types and may similarly provide energy to fuel malignant survival and growth in breast cancer. This relationship is of particular relevance to plastic surgery, because many reconstructions after oncologic mastectomy achieve optimal aesthetics and durability using adjunctive autologous fat transfer (AFT). Despite the increasing ubiquity and promise of AFT, many unanswered questions remain, including safety in the setting of breast cancer. Clinical studies to examine this question are underway, but an in vitro system is critical to elucidate the complex interplay between the cells that normally reside at the surgical recipient site. To study these interactions and characterize possible lipid transfer between adipocytes to breast cancer cells, we designed a 3-dimensional in vitro model using primary patient-derived tissues. Breast adipose tissue was acquired from patients undergoing breast reduction surgery. The tissue was enzymatically digested and sorted to retrieve adipocytes and adipose stromal cells. Polydimethylsiloxane wells were filled with type I collagen-encapsulated adipocytes labeled with the fluorescent lipid dye boron dipyrromethene, as well as unlabeled adipose stromal cells. A monolayer of red fluorescently labeled MDA-MB-231 and MDA-MB-468 breast cancer cells was seeded on the surface of the construct. Lipid transfer at the interface between adipocytes and breast cancer cells was analyzed. Confocal microscopy revealed a dense culture of native adipocytes containing fluorescent lipid droplets in the 3-dimensional collagen culture platform. RFP-positive breast cancer cells were found in close proximity to lipid-laden adipocytes. Lipid transfer from adipocytes to breast cancer cells was observed by the presence of boron dipyrromethene-positive lipid droplets within RFP-labeled breast cancer cells. We have established a 3-dimensional model to study complex breast cancer-adipose tissue interactions. Direct transfer of fluorescently labeled lipids from adipocytes to breast cancer cells may indicate aberrant metabolism to fuel malignant growth and adaptive survival. Our novel platform can untangle the complex interplay within the breast cancer tumor microenvironment for high-throughput analysis and better elucidate the safety of AFT in postoncologic mastectomy.

THE SUPERIOR GLUTEAL FLAP – BREAST RECONSTRUCTION – ANATOMIC DISSECTION ON A CADAVER

The reconstruction of the breast after an oncological mastectomy is a challenge for the plastic surgeons. During the dissection of one fresh, female cadaver, age 63, a free superior gluteal flap was taken from the gluteal region, using loupe magnification. The dissection preparations were photographed with a high definition camera. The harvesting of the superior gluteal musculocutaneous fat-pad flap and the closure of the donor area in layers advantages and disadvantages of using the superior gluteal flap in the reconstruction of the amputated breast.

Skin-reducing Mastectomy with Primary Implant Reconstruction.

Background: We present a series of skin-sparing mastectomies (SSMs) with skin reduction and immediate breast reconstruction to treat large and ptotic breasts. The technique combines oncological mastectomy with immediate subpectoral implant placement as a single-step procedure. Methods: Data was collected from a prospective database from February 2009 to April 2011. A total of 24 patients with macromastia or pronounced ptosis fulfilled the criteria for skin-saving mastectomy. All operations were carried out as a single-step procedure with adaptation of the contralateral breast by reduction mastopexy. Results: A total of 27 SSMs were performed in 24 patients. The mean implant volume was 265 cm3. Immediate reconstruction of the nipple-areola complex was done in 22 patients. The cosmetic and functional results were assessed in all patients 6 months postoperatively; mean follow-up time was 13 months. Mean patient age was 49 years. The cosmetic result was assessed as "very good" or "good" by 22 patients; 2 patients graded the result as "unsatisfactory". There was one local recurrence. Conclusion: Our results support the use of this technique as a safe oncoplastic procedure which is well tolerated by patients.

Objective improvement in upper limb lymphoedema following ipsilaterall latissimus dorsi pedicled flap breast reconstruction – a case series and review of literature

We present a series of three patients whose upper limb lymphoedema (following total oncologic mastectomy and level III axillary clearance) resolved significantly after ipsilateral pedicled latissimus dorsi (LD) flap breast reconstruction. A retrospective review of the medical records of patients who had undergone oncologic mastectomy and level III axillary clearance with subsequent LD pedicled flap reconstruction was carried out. Individuals who had undergone review and treatment by the lymphoedema service were identified and patients with incomplete pre- or post-operative records were excluded. A minimum follow-up period of 2 years of conservative therapy, as well as 2 years post-operatively was undertaken. The rate of improvement of lymphoedema following conservative therapy was, on average, 0.095 mL/week and reached a plateau at 2-year follow-up. Following latissimus dorsi flap breast reconstruction, the rate of improvement in lymphoedema increased in all three cases, with an average improvement of 2.55 mL/week and remained sustained in the follow-up period. Pedicled myocutaneous flap reconstruction of the ipsilateral breast proved to be a useful treatment for upper limb lymphoedema in our series. This adds an important dimension to the assessment and treatment of patients with upper limb oedema resulting from mastectomy and axillary clearance.

321 POSTER Continuous high thoracic epidural anesthesia with 0.125% bupivacaine and fentanyl versus general anesthesia for management of oncologic mastectomy

321 POSTER Continuous high thoracic epidural anesthesia with 0.125% bupivacaine and fentanyl versus general anesthesia for management of oncologic mastectomy

Satisfaction and prosthesis related complaints in women with immediate breast reconstruction following prophylactic and oncological mastectomy

This study evaluated patient's satisfaction with immediate breast reconstruction (IBR) with silicone prosthesis. Special attention is paid to the differences in satisfaction, and specific prosthesis related complaints of IBR after prophylactic and oncological mastectomy. All women who were operated on between April 1995 and May 1999 at the Erasmus Medical Centre, Daniel den Hoed Cancer Centre received 1 year following operation a self-report questionnaire, concerning their perceived advantages of and satisfaction with IBR, their prosthesis-related complaints and various psycho-social variables. The most important perceived advantage of IBR was not to have to wear an external prosthesis (95%). Despite the fact that one third of the patients had specific prosthesis related complaints, 80% was satisfied with IBR and 88% would do it again. There was no significant difference in satisfaction between the prophylactic and the cancer group. Overall satisfaction is mostly influenced by cosmetics (r = − 0.58), information (r = − 0.45) and specific prosthesis related complaints (r = − 0.39). Especially specific prosthesis related complaints are important for both the prophylactic and the cancer group. The majority of patients were satisfied with IBR after oncological or prophylactic mastectomy. However the findings of the importance of specific prosthesis related complaints should be taken serious for the information and care of patients.