Postmastectomy Patients Research Articles

Effects of Treatment With an Elastic Sleeve and Intermittent Pneumatic Compression in Post-Mastectomy Patients With Lymphoedema of the Arm

In an attempt to reduce oedema of the arm after mastectomy, patients were provided with an elastic sleeve which was worn for a period of between 1 week and up to 6 months. A statistically significant mean relative decrease of 17% in the volume of oedema was achieved. Subsequent treatment by intermittent pneumatic compression for 10 days produced a further significant mean relative decrease of 18%. When the sleeve was worn for 6 months after this treatment there was no significant increase in arm volume--that is, no relapse.

Abstract A126: Rural-urban differences in breast reconstruction utilization following mastectomy

Abstract Background: Healthcare disparities in rural women are well-defined, however little is known about breast reconstruction (BR) utilization in this population, especially rural Kentucky. The goal of this study was to determine if disparities in BR exist among post-mastectomy rural female patients in Kentucky. Methods: The Kentucky Cancer Registry was used to identify patients diagnosed with breast cancer and treated with mastectomy from 2006-2015. Patients were subdivided into mastectomy-only and mastectomy plus BR groups. 2013 Beale codes were used to stratify patients according to urban, near-metro or rural status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease and treatment factors was used to predict BR. The likelihood of undergoing BR was reported in odds ratios (OR) using a 95% confidence interval (CI). Results: Overall, 12,036 patients underwent mastectomy. Of these patients, 2,822 (23.4%) also underwent BR. The rate of BR among urban, near-metro and rural patients was 32.4%, 23.1% and 14.7%, respectively. Multivariate analysis revealed that women from near metro (OR 0.56, CI 0.50-0.63; p < 0.001) and rural areas (OR 0.38, CI 0.33-0.43; p <0.001) were less likely to undergo BR than women from urban areas. Conclusion: Although BR benefits are well documented, women from rural areas undergo BR at lower rates and are less likely to receive BR than their urban and near-metro counterparts. While multiple factors contribute to this disparity, future efforts should seek to improve comprehensive breast cancer care which includes access to a reconstructive breast surgeon. Citation Format: Robert-Marlo F. Bautista, Ryan C. DeCoster, Jack C. Burns, Robert W. Edmunds, Adam J. Dugan, Brian J. Rinker, Matthew Webster, Henry C. Vasconez. Rural-urban differences in breast reconstruction utilization following mastectomy [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A126.

Abstract 159: Deformity After Prepectoral Versus Subpectoral Implant-based Breast Reconstruction: A Clinical Outcomes And Differential Costs Analysis

Purpose: Prepectoral implant-based breast reconstruction after mastectomy has regained popularity over subpectoral implant placement in recent years. With the advent of novel tissue replacement matrices and tissue perfusion assessment technologies, prepectoral implant placement has been shown to confer multiple advantages over subpectoral placement, such as reduced animation deformity, decreased pain, and improved muscular function. However, prepectoral implant placement does carry certain disadvantages such as contour deformity and rippling. This study evaluated deformity and revision surgery after prepectoral versus subpectoral breast reconstruction in post-mastectomy patients. Methods: This was an Institutional Review Board-approved retrospective analysis of mastectomy patients undergoing implant-based reconstruction at our institution between October 2016 and July 2019. Medical records were reviewed for patients’ clinical/demographic characteristics, surgeries, outcomes/revisions, and surgical charges. Two-tailed chi square tests and Student’s t test analyses were used where appropriate to compare prepectoral and subpectoral implant groups. Hierarchical multivariate regression was used to generate crude and adjusted odds ratios and 95 percent confidence intervals for outcomes data. The two-tailed threshold for statistical significance was set at p values < 0.05. Results: One-hundred-eighty patients (296 breasts) met inclusion criteria during the study period, of whom, 76 (42.2%) received prepectoral implants and 104 (57.8%) received subpectoral implants. Mean follow-up was 212 days for patients with prepectoral implants and 203 days for subpectoral implants. After adjusting for clinical and demographic factors, a significantly-greater proportion of prepectoral implants developed skin rippling/wrinkling when compared to subpectorally-placed implants (46.5% versus 10.4%, p<0.0001). Similarly, prepectorally-placed implants demonstrated significantly-higher rates of superior pole contour deformity (59.4% versus 38.0%, p=0.02) than subpectoral implants. However, adjusted capsular contracture rates were similar between prepectoral and subpectoral implant cohorts. A significantly-greater proportion of patients with prepectoral implants received fat grafting upon initial implant placement (75.4% versus 37.8%, p<0.0001) as well as revision fat grafting (78.3% versus 42.17%, p=0.03). The mean number of revision surgeries for prepectoral implants was 1.4 (standard deviation: 0.8), which was significantly greater than the mean number of revision surgeries for subpectoral implants was 0.9 (standard deviation: 0.5; p=0.001). Total revision surgery(ies) costs were greater in patients with prepectoral implants than those with subpectoral implants, though this difference reached borderline significance ($3154 versus $1636 respectively, p=0.05). Lastly, upon multivariate hierarchical regression of individual breasts adjusting for anatomic placement of the implant (prepectoral versus subpectoral), lower body mass index independently predicted prepectoral implant contour deformity/rippling (odds ratio: 1.5, 95% confidence interval 1.2-1.8, p=0.02). Conclusion: In our cohort, prepectoral implants were associated with greater postoperative rippling/contour deformity and revision costs than subpectoral implants. Such information could help inform decision-making regarding breast reconstruction, when weighed against previous data demonstrating improved quality of life/decreased pain and narcotic-use following prepectoral placement. Further study is required to comprehensively evaluate cost-effectiveness of prepectoral versus subpectoral implant-based reconstruction, taking into consideration both long-term quality of life and costs.

Abstract 134: Tissue Engineered Neo-nipples Fabricated From Autologous Costal Cartilage Maintain Projection And Biomechanical Properties Of The Native Human Nipple

Purpose: Nipple reconstruction is often cited by post-mastectomy patients as a vital step in their overall reconstruction and recovery. The current gold standard for nipple reconstruction using local skin flaps leads to significant loss of projection and volume. Available commercial scaffolds similarly are unable to maintain projection after only one year post-operatively. We have previously developed a novel technology using biocompatible 3D-printed scaffolds that have demonstrated the ability to maintain the volume, projection and contour of neo-nipples engineered from autologous costal cartilage (CC). Herein, we compare two alternate methods of processing CC, zesting and mincing, and their effect on the ultimate biomechanical properties of the fabricated tissue. Methods: Custom external scaffolds were designed and 3D-printed using polylactic acid (PLA). Patient derived CC was minced into approximately 2-3mm3 portions or flaked by processing with a zesting device into larger 5-6mm3 portions. In both the minced and zested groups, half of the samples were packed into 3D-printed PLA scaffolds (the “scaffolded” group), and in the remainder, an equal volume of processed cartilage was wrapped in Surgicel® only (the “naked” group). The constructs were implanted into nude rats by creating a subcutaneous pocket using a CV flap technique. After 3 months, histological, topographical, and gross analysis were performed on explanted neo-nipples. Biomechanical analysis was performed using confined compression with 5% strain per step up to 30% compression. Samples were prepared with 3mm biopsy punches and cut to 2mm in height for placement into the compression chamber. Results: After 3 months, analysis of biomechanical properties of explanted neo-nipples in the four groups (minced scaffolded, minced naked, zested scaffolded, and zested naked) revealed no significant difference in equilibrium modulus between the native human nipple and minced scaffolded (p = 0.53), minced naked (p = 0.99), zested scaffolded (p = 0.98), or zested naked (p = 0.99) neo-nipples, representing strong recapitulation of native biomechanical properties. Neo-nipples in the zested naked group had the lowest average difference in equilibrium modulus, and thus the greatest similarity to the biomechanical properties of the native human nipple (20.48 kPa). Hematoxylin and eosin staining in both groups showed the presence of healthy and viable cartilage after 3 months in-vivo which was confirmed by LIVE/DEAD assay. Formation of fibrous tissue around the processed CC was noted in both groups. Furthermore, the resultant tissue was spongy and compressible much like a native nipple. Conclusion: We demonstrate that autologous CC, which is usually discarded during a DIEP procedure, can be processed by either zesting or mincing to tissue engineer a viable implant for nipple reconstruction that maintains the biomechanical properties of the native nipple. While our group has previously shown that tissue engineered neo-nipples preserve volume, projection and contour over time, the ability to tissue engineer nipples with similar biomechanical properties to the native human nipple represents a significant advancement.

Regarding the Necessity of Functional Assessment Including Motor Control Assessment of Post-Mastectomy Patients Qualified for Latissimus Dorsi Breast Reconstruction Procedure-Pilot Study.

The purpose of the paper is a functional assessment of post-mastectomy patients who underwent latissimus dorsi breast reconstruction (LDBR), and of healthy women, through an analysis of selected muscle function parameters, including motor control assessment. Twenty participants were included in the study (ten LDBR-procedure individuals and ten healthy controls). The research consisted of a DASH (The Disabilities of the Arm, Shoulder and Hand) questionnaire assessment, shoulder area static assessment, shoulder mobility assessment, latissimus dorsi flexibility assessment and shoulder motor control assessment. LDBR-procedure individuals—when compared to healthy controls—exhibited a decrease in physical aspects of quality of life, shoulder area postural alterations, limitations in shoulder mobility and decrease in shoulder motor control. LDBR procedure may have an influence on limiting shoulder active mobility, as well as on decrease of shoulder motor and postural control. Standard functional assessment diversified on motor control assessment of post-mastectomy patients qualified for the LDBR procedure seems to be necessary.

Predictors of post-mastectomy breast reconstruction in Kenya

Background: Breast reconstruction following mastectomy has mental and physical health benefits. Several patient-centered factors predict the rate of breast reconstructions. We investigated the rates and predictors of breast reconstruction in postmastectomy patients diagnosed with breast cancer at a teaching and national referral center. Methods: A retrospective case-control study involving post-mastectomy females diagnosed with breast cancer from 2014 to 2018. Logistic regression evaluated potential predictors of breast reconstruction. Results: 312 women had mastectomies during the 5-year study period: 9 (2.88%) had breast reconstruction—all breast reconstructions were autologous (latissimus flap). The rate of reconstruction increased over the study period, then dropped in 2018. Factors significantly affecting the rate of breast reconstruction included patient age and insurance coverage. Conclusion: In this hospital-based study, the rate of post-mastectomy breast reconstruction is low, despite the procedure being an essential component of breast cancer care. Age and insurance coverage are predictors for breast reconstruction. Keywords: Breast reconstruction, Rates, Hospitalbased, Predictors

Effectiveness of Rhythmic Chopping &amp; Lifting Pattern on Shoulder Range of Motion and Upper Extremity Functional Index in Post:Mastectomy Patients

Objective: T o determine the effect of Rhythmic chopping &amp; lifting pattern on shoulder range of motion in Post-mastectomy patients. Method: A total 40 subjects were taken according to inclusion and exclusion criteria. Each subject was assessed by using Shoulder goniometry and UEFI questionnaire. Result: A statistical analysis showed that Rhythmic chopping and lifting PNF exercises showed significant improvement in the outcome variables concluding that it improves shoulder ROM and functional activities. Conclusion: Analysis of all the data obtained through the outcome measures (UEFI Questionnaire and shoulder ROM) shows that Rhythmic chopping and lifting PNF exercises showed significant improvement in the outcome variables concluding that it improves shoulder ROM and functional activities.

Association Between Delayed Diagnosis Of Breast Cancer And Its Degree Of Invasiveness Among The Patients In Tertiary Care Hospital Of Karachi

Objective: To find the association between delayed diagnosis of breast cancer over the degree of invasiveness for each of the immune-histochmically defined molecular type of invasive ductal carcinoma among the patient in tertiary care hospital of Karachi. Study Design and Setting: A cross sectional study was conducted on 153 post mastectomy patients in a time frame of two years at Bait-ul-Sukoon Hospital who had their immunohistochemistry workup. Methodology: The patients included in the research were diagnosed cases of breast cancer; had post-mastectomy with their histopathological and immunochemistry status work up reports. In addition to demographic variables; the histopathological report of specimen, histological tumor type and grade, invasive tumor size, axillary lymph node status, Paget’s disease and stage of the disease were recorded from the histopathological report however ER, PR and Her 2 neu receptor statuses were confirmed via immunochemistry report. Volume of the tumor was calculated using the following formula V = (W2 × L)/2 Convenient sampling was applied and the data was analyzed on SPSS 20.0 with CI-95% and P=0.05. Results- All 153 patients reported because of unpleasant symptoms.47.1% of the participants presented with LT while the remaining 52.9% were grouped as NLT. The association of molecular type with stage at mastectomy was statistically significant (P=0.015) in the ERG. Her-2 enriched variant shows that there was a moderate positive statistically significant relationship between log of total delay and log of tumor volume +2. Conclusion: Delay in diagnosis due to lack of screening modalities, lesser awareness among low socioeconomic groups and inaccessibility to tertiary care were not the major causes of aggressive tumors at diagnosis in developing countries, instead all the major known risk factors influence to the tumor burden collectively

Utilization of Physical Therapy Services for Post-Mastectomy Patients: A Prevalence Study

Utilization of Physical Therapy Services for Post-Mastectomy Patients: A Prevalence Study

Update in Direct-to-Implant Breast Reconstruction

Implant-based reconstruction (IBR) remains the most commonly utilized breast reconstruction option for post-mastectomy patients. IBR can be approached as either a one-stage reconstruction or a two-stage reconstruction. Facilitated by improvements in surgical technology and advanced techniques, one-stage reconstruction, also known as direct-to-implant (DTI) reconstruction, involves the insertion of an implant at the time of mastectomy. The decision to pursue either a DTI or a two-stage reconstruction is based on several factors, including the patient's overall health, expected risk of postoperative complications, and associated costs to both the patient and hospital.

Dosimetric comparison between volumetric-modulated arc therapy and a hybrid volumetric-modulated arc therapy and segmented field-in-field technique for postmastectomy chest wall and regional lymph node irradiation

Decreasing radiotoxicity to the heart, lungs, and contralateral breast has proven to lower the risk of secondary malignancy and improve overall outcomes when treating chest wall (CW) and regional lymph nodes in postmastectomy breast cancer patients. In this retrospective study, 11 postmastectomy patients were selected and planned with a novel hybrid treatment method and a traditional volumetric arc therapy (VMAT) approach for comparison. This hybrid technique was able to optimize tangential beams to minimize heart dose and the VMAT contribution to improve dose conformity around the planning target volume (PTV). Overall, this hybrid technique produced more homogenous target dose coverage and demonstrated a decrease of integral dose to organs at risk (OAR), while the VMAT technique demonstrated a higher affinity for maintaining dose conformity. Further observation of dose distributions also revealed that the hybrid plans were more effective in sparing low-dose spread to healthy tissue in both right- and left-sided cases. This observation was made evident by the reduction in heart V5 and Dmean, decreases in all parameters regarding the contralateral lung, as well as all values other than the V20 of the ipsilateral lung. This unique hybrid planning technique could present an alternative to standard intensity-modulated radiation therapy (IMRT) planning when treating postmastectomy CW and regional lymph nodes, as it has shown the capacity to decrease cardiac, lung, and contralateral breast toxicity while maintaining quality PTV coverage.

Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients.

Background:As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement.Methods:A retrospective review of postmastectomy patients with expander-to-implant reconstruction by one reconstructive surgeon was performed. All patients were treated with immediate expander and ADM placement at the time of mastectomy. Irradiated patients underwent a separate lipotransfer procedure after completion of radiotherapy but prior to prosthesis exchange. Our study compared postoperative outcomes between non-radiated patients and irradiated patients who underwent this intermediary lipotransfer. Clinical endpoints of interest included: overall complications, infection, delayed wound healing, dehiscence, capsular contracture, implant failure, and reoperation.Results:One hundred and thirty-one breast reconstructions were performed; 18 (13.74%) were irradiated and 113 (86.26%) were not. Overall complication risk (infection, implant failure, or reoperation) was no higher in irradiated breasts treated with lipotransfer than non-irradiated breasts (p=0.387). Fifteen patients who had one radiated and one non-radiated breast were separately analyzed; no difference in complication by radiotherapy exposure (p=1) was found. Age, BMI, smoking status, and nipple-sparing versus skin-sparing mastectomy did not vary significantly between study groups (p=0.182, p=0.696, p=0.489, p=1 respectively).Conclusions:Comparable postoperative outcomes were found between non-radiated breasts and radiated breasts treated with intermediary lipotransfer. The ameliorating effects of autologous lipotransfer on radiotoxicity may therefore offer irradiated patients the option of expander-to-implant reconstruction with acceptable risk and cosmesis.

Multi-stage fat grafting for total breast reconstruction after mastectomy

Post-mastectomy patients who are unwilling or deemed too high risk for implant or flap-based reconstruction have an alternative option for breast reconstruction. Our study evaluated the use of multi-stage fat grafting after mastectomy for total breast reconstruction. Our technique produced successful aesthetic outcomes in terms of both volume and shape. In certain patient populations, serial, staged fat grafting is a viable alternative that can produce satisfactory results with minimal complications or donor site morbidity.

The Potential Role of Intensity-modulated Proton Therapy in the Regional Nodal Irradiation of Breast Cancer: A Treatment Planning Study

AimsTo investigate the role of intensity-modulated proton therapy (IMPT) for regional nodal irradiation in patients with breast carcinoma in comparison with volumetric-modulated arc therapy (VMAT). Materials and methodsA cohort of 20 patients (10 in the breast-conserving surgery group and 10 post-mastectomy patients with tissue expander implants) was investigated. Proton plans were also computed using robust optimisation methods. Plan quality was assessed by means of dose–volume histograms and scored with conventional metrics. Estimates of the risk of secondary cancer induction (excess absolute risk, EAR) were carried out, taking into account fractionation, repopulation and repair. ResultsConcerning target coverage, the data proved a substantial equivalence of VMAT and IMPT: for example, coverage for the 50 Gy target, expressed in terms of V98%, was 47.8 ± 0.4, 47.6 ± 0.4, 47.3 ± 0.8, consistent with the objective of 47.5 Gy, for post-mastectomy patients for the three groups of patients. Also, the conformality of the dose distributions was similar for the two techniques, about 1.1, without statistically significant differences. Organ at risk planning aims were achieved for all structures for both techniques. The mean dose to the ipsilateral lung was 10.8 ± 1.1, 6.2 ± 0.8, 7.2 ± 1.0; for the contralateral lung was 3.2 ± 0.7, 0.3 ± 0.2, 0.4 ± 0.2; for the contralateral breast was: 3.1 ± 0.7, 0.3 ± 0.3 and 0.3 ± 0.3, whereas it was 3.9 ± 0.9, 0.4 ± 0.3 and 0.5 ± 0.5, respectively, for the heart for VMAT, IMPT and robust IMPT plans over the whole group of patients. Robust optimisation affected the near-to-maximum dose values for contralateral lung and breast, the mean dose for the heart and ipsilateral lung, with a deterioration ranging from 20 to 40% of the nominal value of IMPT plans (e.g. from 8.1 ± 6.4 to 11.4 ± 8.8 for the heart compared with 16.2 ± 5.2 for the VMAT plans). The numerical values of EAR per 10 000 patient-years were about one order of magnitude higher for VMAT than for IMPT for contralateral structures: 11.66 ± 2.01, 0.89 ± 0.80, 0.98 ± 0.77 for the contralateral breast and the three groups of plans, respectively; 14.31 ± 2.75, 1.42 ± 0.80, 1.78 ± 0.87 for the contralateral lung; and 34.86 ± 2.64, 18.85 ± 2.15, 20.98 ± 2.35 for the ipsilateral lung. ConclusionIMPT with or without robust optimisation seems to be a potentially promising approach for the radiation treatment of breast cancer when nodal volumes should be irradiated. This was measured in terms of dosimetric advantage and predicted clinical benefit. In fact, the significant reduction in estimated EAR could add further clinical value to the dosimetric sparing of the organs at risk achievable with IMPT.

Innovative post mastectomy bra for increasing self-convenience and confidence patients

Background: The act of mastectomy can affect body image because it loses part of the body and affects their social relationships with others. The existed bra is felt uncomfortable when worn so it is necessary to develop a special post mastectomy bra to increase the confidence and comfort of post mastectomy patients.Purpose: This study aimed to examine and develop a special post mastectomy bra to increase self-confidence in post-mastectomy patients.Research Methods: This is a Research and Development (R &amp; D) research. This study consisted of 3 phase, namely research phase I, phase II, and phase III or product testing.Results: The results of a post mastectomy special bra tested to 10 respondents mentioned that a special post mastectomy bra is comfortable to wear and they are not ashamed anymore do activities outside the home.Conclusion: Special post mastectomy bras are proven to increase post-mastectomy patients' convenience and confidence.

Classification of breast tissue expander infections: Back to the basics.

Infections following tissue expander (TE) placement are frequent complications in breast reconstruction. While breast surgery is a clean case, implant-based breast reconstruction has rates of infection up to 31%, decidedly higher than the typical 1% to 2% rate of surgical site infections (SSI). Few authors use the Center for Disease Control's (CDC) SSI definition for TE infections. We highlight how adoption of a consistent definition of TE infection may change how infections are researched, categorized, and ultimately managed. Two researchers with definitional discrepancies of infection performed an independent analysis of all postmastectomy patients receiving TEs (n = 175) in 2017. Researcher One, using a clinical definition, delineated an infection rate of 19.4%. Antibiotics alone successfully treated 50% of cases. Researcher Two found an infection rate of 13.7% using CDC criteria. These infections were further delineated by a SSI rate of 6.3% and a TE infection rate post port access of 7.4%. Only 45.5% SSI's and 15.4% of TE infections were salvaged with antibiotics alone. Rigorous adoption of CDC criteria for infection characterization in published research will help standardize the definition of infection and allow surgeons to create evidence-based infection prevention regimens.

Utility and Outcomes of Imaging Evaluation for Palpable Lumps in the Postmastectomy Patient.

OBJECTIVE. The objective of our study was to assess the utility of targeted breast ultrasound and mammography in evaluating palpable lumps in the mastectomy bed. MATERIALS AND METHODS. This retrospective study identified postmastectomy patients who presented for initial imaging evaluation of palpable lumps between January 2009 and December 2015. Clinical, imaging, and pathology results were reviewed. Surgical reconstruction type and percutaneous sampling data were collected. Patients were excluded if they had known malignancy at imaging presentation, if the palpable lump was not at the mastectomy site, or if there was less than 1 year clinical or imaging follow-up in the absence of biopsy. Each palpable site was assigned as a case, and analyses were performed at the case level. RESULTS. Among the 101 patients with a history of prophylactic or therapeutic mastectomy who presented during the study period, 118 palpable cases met the inclusion criteria. All 118 cases were evaluated with ultrasound and 43 with mammography. Among the 75 cases evaluated with ultrasound alone, nine cancers were detected. Among the 43 cases evaluated with both ultrasound and mammography, three cancers were sonographically detected, of which two were mammographically visible and one was mammographically occult. There were two false-negative ultrasound cases; both underwent sampling because of the level of clinical suspicion. In total, 14 palpable lumps in 12 patients were malignant, and 104 palpable lumps in 89 patients were nonmalignant. Targeted ultrasound yielded a negative predictive value (NPV) of 97% and a positive predictive value 2 of 27%. CONCLUSION. Our data suggest that targeted breast ultrasound, with its high NPV, should be the initial imaging test of choice for palpable lumps after mastectomy. Mammography yielded no additional cancers but was helpful in confirming benign diagnoses. The two false-negative ultrasound cases support palpation-guided sampling for imaging-occult and clinically suspicious palpable lumps.

Combined Surgical Treatment for Chronic Upper Extremity Lymphedema Patients: Simultaneous Lymph Node Transfer and Liposuction.

Upper limb lymphedema is a common problem after axillary lymph node dissection. Lymphatic drainage can be improved by microvascular lymph node transfer, whereas liposuction can be used to reduce arm volume and excess of adipose tissue. We present the results of chronic lymphedema patients who have undergone lymph node transfer and liposuction simultaneously in 1 operation and compare the results with patients who have undergone lymph node transfer without liposuction. During May 2007 to February 2015, 20 postmastectomy patients and 1 Hodgkin's lymphoma patient presenting with chronic nonpitting lymphedema (age between 37 and 74 years, average 56.7 years) were operated using the combined technique and 27 postmastectomy patients presenting with early-stage lymphedema (age between 31 and 68 years, average age 50.2 years) were operated using only the lymph node transfer. Compression therapy was started immediately after the operation and the patients used compression 24 h/d at least 6 months postoperatively. Changes in clinical parameters (number of erysipelas infections, pain), arm volume, transport indexes calculated form lymphoscintigraphy images, and daily usage of compression garments were compared preoperatively and postoperatively and between groups (combined technique vs lymph node transfer). The study was a retrospective observational study. In the combined technique group, the average arm volume excess decreased postoperatively 87.7%, and in 7 of 10 patients, the edema volume did not increase even without compression. Seventeen of 21 patients were able to reduce the use of compression garment. Lymphoscintigraphy results were improved in 12 of 15 patients and the improvement was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.01). The number of erysipelas infections was decreased in 7 of 10 patients and the decrease was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.02). In the lymph node transfer group, the average excess volume decreased postoperatively 27.5%. Fourteen of 27 patients were able to reduce the use of compression garments. Lymphoscintigraphy results were improved in 8 of 19 patients, and the number of erysipelas infections was decreased in 1 of 3 patients. Liposuction can safely be performed with lymph node transfer in 1 operation to achieve optimal results in patients with chronic lymphedema. The combined technique provides immediate volume reduction and further regenerative effects on the lymphatic circulation. The significantly greater reduction in lymphoscintigraphy values and erysipelas infections suggests that the combined technique might be better for late-stage lymphedema patients than lymph node transfer alone.

Shoulder Pain and Disability Among Post Mastectomy Patients

Abstract Purpose The purpose of this study was to determine shoulder pain and disability among post mastectomy patients. Methods This cross sectional study was conducted in Peshawar Pakistan from June 2017 to June 2018. A self administered questionnaire was used to collect demographic information and clinical characteristics while Shoulder Pain and Disability Index (SPADI) was used to evaluate shoulder pain and disability. Female post mastectomy patients with age between 18 to 55 years were included. Patients with co-morbidities, bilateral mastectomy, history of trauma, history of shoulder pain before mastectomy and shoulder pain on non-operated side were excluded. SPSS version 23 was used to analyze the data. Results A total of 127 post mastectomy patients participated in the study. Out of total 127 participants, 99 (77.95%) reported shoulder pain and disability on operated site. Age (P value=0.181) and operated side i. e., right and left mastectomy (P value=0.324) were not significantly associated with shoulder pain and disability. On the other hand marital status (P value=0.04), educational status (P value=0.03) profession (P value&lt;0.001) and time since surgery (P value=0.04) were significantly associated with shoulder pain and disability. Conclusion More than 2 third of post mastectomy patients suffer from shoulder pain and disability. Connective tissue fibrosis of shoulder joint seems to be the only reason for it. Physical therapy after mastectomy can help in preventing shoulder pain and disability.

Staged immediate nipple reconstruction with tube flap in secondary autologous breast reconstruction

In the setting of secondary breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, the mastectomy skin is usually deepithelialized and buried under the reconstructed breast. In this study, by virtue of tube flap technique, we hypothesize that an amount of mastectomy skin could be transferred to the apex of reconstructed breast mound for nipple reconstruction. A total of 30 female postmastectomy patients were recruited between June 2012 and August 2015. A bipedicle DIEP flap was harvested and folded upward to reconstruct the breast. An inferiorly based mastectomy flap was raised and rolled into a tube. The free end of the flap was sutured to the reconstructed breast mound to allow revascularization. After serial stages, a sufficient tissue bulk from the mastectomy flap was transferred to the apex of the breast mound and remolded into a new nipple. Reconstructed breasts and nipples survived well postoperatively. The mean nipple projection was 9.2 ± 2.7 mm at the 1-year follow-up. In total 24 patients ranked the overall nipple and breast reconstruction to be very good or good. Based on DIEP flap breast reconstruction, the staged immediate nipple reconstruction with local mastectomy tube flap could maintain a long term residual projection with aesthetically acceptable outcomes.