Breast Reconstruction Procedures Research Articles

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction: A Meta-analysis Based on Matched Cohort Studies.

Autologous fat grafting has become a commonly used procedure for breast reconstruction after breast cancer surgical treatment. Nevertheless, oncological considerations remain concerning autologous fat grafting after breast cancer surgery. This meta-analysis aimed to summarize the current matched cohort studies and provide high-quality evidence-based conclusions on the oncological safety of fat grafting in breast reconstruction. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. A literature search was performed on August 1, 2021, using PubMed. All relevant matched cohort studies of patients undergoing autologous fat grafting after breast cancer surgery were included. After independently screening the studies and extracting the data, pooled estimates for local and regional recurrence as well as distant metastases were conducted using Review Manager software (RevMan, version 5.3). Outcomes were expressed as odds ratios and 95% confidence intervals. Seventeen studies involving 7494 patients were included. The observed outcomes indicated that no significant differences existed in the risks of local and regional recurrence or distant metastases between autologous fat grafting and control groups. Also, there was no significant heterogeneity among the studies. This study provided evidence-based conclusions that support the use of autologous fat grafting in breast reconstruction. 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 .

Defining the Ideal Breast Reconstruction Procedure After Mastectomy From the Patient Perspective: A Retrospective Analysis.

Background:An increasing number of breast cancer patients undergo immediate or secondary breast reconstruction, but the ideal method in terms of patient satisfaction remains ambiguous. We compared the 3 most common breast reconstruction techniques to determine patient satisfaction and objective outcomes.Methods:Retrospective study of 184 patients with breast cancer who underwent a reconstructive procedure between 1993 and 2011 at our institution. Procedures evaluated were implant-based reconstruction (IBR) alone, latissimus dorsi (LD) flap reconstruction with/without implant, and deep inferior epigastric perforator (DIEP) free flap reconstruction. A retrospective patient satisfaction questionnaire was sent to all women. Twenty patients from each subgroup were matched to conduct a standardized objective assessment of the sensitivity of their reconstructed breast. A blinded photographic evaluation was also performed by 3 independent observers to assess the esthetic aspect and symmetry.Results:DIEP obtained significantly higher average scores regarding the esthetic outcome, immediate reconstruction impact, and overall score in the questionnaire evaluation. The IBR had the best results in the somatosensory evaluation, with DIEP scoring better than LD. DIEP received higher scores on average than LD for the criteria of size and symmetry in the esthetic evaluation. No statistically significant differences were observed between IBR and DIEP.Conclusions:Good results were reported overall for all breast reconstruction procedures, with more reserved scores for LD. The DIEP reconstruction appeared to be the most satisfactory and best experienced reconstruction method for patients, despite the complexity of the intervention. Clinicians should be encouraged to consider DIEP as the principal choice for breast reconstruction.

An Analysis of the Modified Five-Item Frailty Index for Predicting Complications following Free Flap Breast Reconstruction.

The modified five-item frailty index is a validated and effective tool for assessing risk in surgical candidates. The authors sought to compare the predictive ability of the modified five-item frailty index to established risk factors for complications in free flap breast reconstruction. The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for free flap breast reconstructive procedures. Univariate and multivariate regression analysis models were used to assess how modified five-item frailty index and factors commonly used to risk stratify (age, body mass index, American Society of Anesthesiologists classification, and history of smoking) were associated with complications. Of the total 10,550 cases, 24.1 percent experienced complications. A high modified five-item frailty index score is associated with a higher overall rate of postoperative complications (p < 0.001). This significant trend was demonstrated in both surgical (p < 0.001) and medical (p < 0.001) complications. When controlling for other risk factors commonly used for risk stratification such as age, body mass index, American Society of Anesthesiologists classification, and history of smoking, the modified five-item frailty index was significantly associated with medical (OR, 1.75; 95 percent CI, 1.37 to 2.22; p = 0.001) and any complications (OR, 1.58; 95 percent CI, 1.29 to 1.93; p < 0.001) and had the largest effect size. Assessing for specific complications, the modified five-item frailty index is the strongest independent predictor of reoperation (OR, 1.41; 95 percent CI, 1.08 to 1.81; p = 0.009). The modified five-item frailty index is a useful predictor of postoperative outcomes in patients undergoing free flap breast reconstruction when compared to other historically considered risk factors for surgical complications. Risk, III.

Teaching Microsurgical Breast Reconstruction-A Retrospective Cohort Study.

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, ”no-training group”), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery (“passive training”); by the trainee, and a senior surgeon was supervising (“active training”); or by the trainee without a senior surgeon (“after training”). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database.

Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates. The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates. A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02). Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates. Risk, III.

Long-Term Outcomes of Lymph Node Transfer in Secondary Lymphedema and Its Correlation with Flap Characteristics.

Simple SummaryUpper limb lymphedema is a common complication following breast cancer treatment. Vascularized Lymph Node Transfer (VLNT) is an emerging therapeutic modality with satisfactory outcomes. However, surgical complexity and potential donor-site morbidity may complicate its application. The aim of our retrospective study was to assess the impact of certain lymph node flap characteristics on long-term outcomes. In a series of 64 post-mastectomy lymphedema patients who underwent VLNT with the Selected Lymph Node technique, we confirmed a positive correlation between lymph node flap size and number of lymph nodes transferred, as well as between flap size and achieved lymphedematic volume reduction. Lymphedema stage and flap vascular pedicle had no significant impact on the final results. These findings underline the necessity for meticulous flap choice, in order to combine a flap harvest of adequate size with more favorable outcomes and minimized donor site morbidity.Background: This retrospective study aimed to assess the impact of certain flap characteristics on long-term outcomes following microsurgical treatment in Breast Cancer-Related Lymphedema (BCRL) patients. Methods: Sixty-four out of 65 BCRL patients, guided by the “Selected Lymph Node” (“SeLyN”) technique, underwent Vascularized Lymph Node Transfer (VLNT) between 2012 and 2018. According to their surface size, flaps were divided into small (<25 cm2, n = 32) and large (>25 cm2, n = 32). Twelve large and six small flaps were combined with free abdominally based breast reconstruction procedures. Lymphedema stage, flap size, vascular pedicle and number of lymph nodes (LNs) were analyzed in correlation with long-term Volume Differential Reduction (VDR). Results: At 36-month follow-up, no major complication was recorded in 64 cases; one flap failure was excluded from the study. Mean flap size was 27.4 cm2, mean LNs/flap 3.3 and mean VDR 55.7%. Small and large flaps had 2.8 vs. 3.8 LNs/flap (p = 0.001), resulting in 49.6% vs. 61.8% VDR (p = 0.032), respectively. Lymphedema stage and vascular pedicle (SIEA or SCIA/SCIP) had no significant impact on VDR. Conclusion: In our series, larger flaps included a higher number of functional LNs, directly associated with better outcomes as quantified by improved VDR.

Current trends in breast reconstruction.

Breast reconstruction is nowadays a component of surgical treatment of breast cancer; therefore plastic surgeons are widely involved in breast reconstruction procedures either after mastectomy or after wide quadrantectomy. The aim is to reduce the distortion of breast shape and to improve the aesthetic outcome of the oncological procedure taking in account the symmetric appearance of the breasts. In post quadrantectomy reconstruction, breast reshaping with mammoplasty pattern could be applied in large and ptotic breast; otherwise flaps from lateral thoracic area could be used as well in post mastectomy reconstruction. In the case of mastectomy, the mastectomy procedure itself has become increasingly conservative, thus allowing an improvement in the aesthetic results of the reconstruction, especially if an implant is used. If adequate thickness of the mastectomy flap is preserved, the prosthesis can be placed in front of the muscle (prepectoral reconstruction), rather than behind the muscle (submuscular reconstruction). In prepectoral reconstruction the postoperative recovery is easier and less distressing for the patient and the postoperative appearance is more natural then in submuscular reconstruction. Autologous breast reconstruction implies the use of flaps (tissue taken from donor areas and used to reconstruct the breast area after appropriate molding), this technique allows to obtain a natural appearance of the breast with similar characteristics to the original one, and can be used in the radiated field. Different options of flaps include flaps from back area (local flaps) and flaps from distant areas (free flaps), basically from abdomen and inner tight.

Comparison of outcomes between immediate implantbased and autologous reconstruction: 15-year, single-center experience in a propensity score-matched Chinese cohort.

Objective:The number of immediate breast reconstruction (IBR) procedures has been increasing in China. This study aimed to investigate the oncological safety of IBR, and to compare the survival and surgical outcomes between implant-based and autologous reconstruction.Methods:Data from patients diagnosed with invasive breast cancer who underwent immediate total breast reconstruction between 2001 and 2016 were retrospectively reviewed. Long-term breast cancer-specific survival (BCSS), disease-free survival (DFS), and locoregional recurrence-free survival (LRFS) were evaluated. Patient satisfaction with the breast was compared between the implant-based and autologous groups. BCSS, DFS, and LRFS were compared between groups after propensity score matching (PSM).Results:A total of 784 IBR procedures were identified, of which 584 were performed on patients with invasive breast cancer (implant-based, n = 288; autologous, n = 296). With a median follow-up of 71.3 months, the 10-year estimates of BCSS, DFS, and LRFS were 88.9% [95% confidence interval (CI) (85.1%–93.0%)], 79.6% [95% CI (74.7%–84.8%)], and 94.0% [95% CI (90.3%–97.8%)], respectively. A total of 124 patients completed the Breast-Q questionnaire, and no statistically significant differences were noted between groups (P = 0.823). After PSM with 27 variables, no statistically significant differences in BCSS, DFS, and LRFS were found between the implant-based (n = 177) and autologous (n = 177) groups. Further stratification according to staging, histological grade, lymph node status, and lymph-venous invasion status revealed no significant survival differences between groups.Conclusions:Both immediate implant-based and autologous reconstruction were reasonable choices with similar long-term oncological outcomes and patient-reported satisfaction among patients with invasive breast cancer in China.

Volumetric change of the latissimus dorsi muscle after postoperative chemotherapy and radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap: final results from serial studies.

BackgroundBreast reconstruction using an extended latissimus dorsi (eLD) flap can supplement more volume than reconstruction using various local flaps after partial mastectomy, and it is a valuable surgical method since the reconstruction area is not limited. However, when performing reconstruction, the surgeon should consider latissimus dorsi (LD) volume reduction due to postoperative chemotherapy (POCTx) and postoperative radiotherapy (PORTx). To evaluate the effect of POCTx and PORTx on LD volume reduction, the effects of each therapy—both separately and jointly—need to be demonstrated. The present study quantified LD volume reduction in patients who underwent POCTx and PORTx after receiving breast-conserving surgery (BCS) with an eLD flap.MethodsThis study included 48 patients who received immediate breast reconstruction using an eLD flap from January 2013 to March 2017, had chest computed tomography (CT) 7–10 days after surgery and 10–14 months after radiotherapy completion, and were observed for more than 3 years postoperatively. One surgeon performed the breast reconstruction procedures, and measurements of breast volume were obtained from axial CT views, using a picture archiving and communication system. A P-value <0.05 was the threshold for statistical significance.ResultsThe average volume reduction of LD at 10–14 months after completing POCTx and PORTx was 64.5% (range, 42.8%–81.4%) in comparison to the volume measured 7–10 days after surgery. This change was statistically significant (P<0.05).ConclusionsBased on the findings of this study, when harvesting an eLD flap, surgeons should anticipate an average LD volume reduction of 64.5% if chemotherapy and radiotherapy are scheduled after BCS with an eLD flap.

Oncological Safety of Lipofilling in Patients with Breast Cancer: A Metaanalysis

Abstract Background Lipofilling is an increasingly popular technique for breast reconstruction following both mastectomy and breast-conserving surgery (BCS). Autologous fat transfer (Lipofilling), is a technique which has been used for many years in the setting of aesthetic breast surgery. Although gaining popularity in this setting, there are still questions regarding its oncological safety when used in patients being treated for breast cancer. Objective To systematically evaluate the current literature regarding the oncological safety of lipofilling in patients who underwent surgical treatment for breast cancer by performing a metaanalysis to investigate the recurrence rates and the incidence of complications after lipofilling. Data Sources: Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materi als available in the Internet till 2019. Data Extraction All the studies which did not fulfill the inclusion criteria were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion Through this analysis, no evidence that lipofilling significantly increases the risk of locoregional recurrence when used as part of a breast reconstruction procedure after either mastectomy or BCS for breast cancer was found. Therefore, it can be considered an oncologically safe procedure in suitable patients with careful oncological follow-up. In the future, more longterm, adequately powered, multicentre controlled studies are needed. Additionally, more research should be carried out on the incidence of complications following lipofilling so that efforts can be made to prevent them and optimise fat graft survival.

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study.

Background:The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions.Methods:This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay.Results:Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome.Conclusions:The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.

Laparoscopic Abdominal Surgery after Primary Breast Reconstruction Using an Abdominal Flap

Background and objectives: Our department has been performing primary breast reconstruction for breast cancer surgery, incorporating a transverse rectus abdominis myocutaneous flap (TRAM)/vertical rectus abdominis myocutaneous flap (VRAM) since 1998 and a deep inferior epigastric artery perforator flap (DIEP) since 2008. Currently, most gastrointestinal operations in abdominal surgery are performed laparoscopically or are robot-assisted. Cases in which abdominal surgery was performed after breast reconstruction using an abdominal flap were reviewed. Method: A total of 119 cases of primary breast reconstruction using an abdominal flap performed in our department were reviewed. Result: The reconstructive techniques were DIEP in 69 cases and TRAM/VRAM in 50 cases. After breast surgery, seven abdominal operations were performed in six cases. In DIEP cases, one robotic surgery was performed for uterine cancer, and one laparoscopic surgery was performed for ovarian tumor. In TRAM/VRAM cases, two laparoscopic cholecystectomies, one laparoscopic total gastrectomy, one laparoscopic ileus reduction, and one open total hysterectomy oophorectomy were performed. Six surgeries were completed by laparoscopy or robotic assistance. Conclusion: The survival rate after breast cancer surgery is improving, and the choice of breast reconstruction procedure should take into account the possibility of performing a prophylactic resection of the ovaries due to the genetic background and possibly postoperative abdominal surgery due to other diseases. However, in cases in which laparoscopic surgery was attempted after breast reconstruction using an abdominal flap, the laparoscopic surgery could be completed in all cases.

Goldilocks Procedure without a Vertical Incision and a Comprehensive Literature Review.

Background:The Goldilocks technique is a postmastectomy breast reconstruction procedure adopted in 2012, which is performed by preserving and de-epithelializing the residual mastectomy flap to create an autologous tissue breast mound using an anchor, inverted T, or lateral incision. It is utilized in select patients along with the addition of a free nipple graft, fat grafting, and/or tattoo. A novel technique using the Goldilocks procedure offers promising postoperative results as a more aesthetic alternative. The purpose of this study was to perform a literature review on the healing outcomes and patient satisfaction of the Goldilocks procedure along with presenting our approach using a horizontal inframammary incision without a vertical incision.Methods:A retrospective chart review of patients presenting to a single surgeon for breast reconstruction surgery using the Goldilocks procedure without a vertical incision from March of 2018 to October of 2020 was performed. A narrative literature review on surgical techniques and outcomes was also conducted.Results:Three cases of breast reduction using the Goldilocks procedure without a vertical incision are described. From the literature search, 13 articles inclusive of 222 patients were identified.Conclusions:The Goldilocks procedure without a vertical incision can be performed in patients with large breasts for breast reconstruction postmastectomy. It is possible to utilize the superior flap in conjunction with the de-epithelialized inferior flap of the breast and obtain good projection with this method. Furthermore, avoidance of the vertical incision reduces breakdown at the T-junction and is aesthetically beneficial.

Modified Breast Band Improving the Postoperative Breast Augmentation and Reconstructive Experience

Background: Superior displacement of implants is a common complication in the early postoperative period following breast augmentation surgery. Postoperative breast bands are used during the first 4 weeks to optimize breast implant position following breast augmentation and reconstructive procedures. Although currently available breast bands are effective in maintaining implants in an inferior position, they have been observed to irritate the armpit region. We hypothesized that a modified breast band geometry with cut outs to accommodate the armpit region would provide equal maintenance of desired implant position while providing improved postoperative comfort. Methods: Forty patients who underwent breast augmentation and/or reconstruction were randomly assigned to receive either the traditional breast band or the modified cut out designed breast band following surgery for 4 weeks. Patients rated their breast bands on a 1 to 10 scale regarding (1) comfort, (2) appearance, and (3) overall satisfaction at their routine postoperative visits at 1, 2, and 4 weeks following surgery. Results: The modified breast band scored higher for all factors at 1, 2, and 4 weeks following surgery. The traditional band demonstrated decreasing scores for comfort and overall satisfaction when compared at 4 weeks versus 1 week. There was no change in the modified breast band scores for comfort, appearance, nor overall satisfaction over the same time period. Discussion: This study of 40 patients found that the modified band provides equally effective maintenance of implants in a desired position without compromising comfort and appearance. Patients who used the modified band had a better experience with the band comfort, appearance, and overall satisfaction in comparison to the traditional band. The higher ratings for the cut out band for comfort, appearance, and overall satisfaction were consistent from week 1 to 4. Conclusion: In contrast, the traditional band not only scored lower in comfort, appearance, and overall satisfaction compared to the modified band but also demonstrated significant decrease in the patients’ ratings for comfort and overall satisfaction for the traditional band from week 1 to 4. This study supports the conclusion that a modified cut out breast band design provides an equally effective maintenance of implants in a desired position without compromising comfort, appearance, and overall satisfaction when compared to the traditional band.

Breakthrough in breast reconstruction in the context of COVID-19: safety and efficiency of endoscopic breast reconstruction at a day surgery center

In recently years, breast endoscopic reconstruction surgery is becoming increasingly popular. And we have explored a series of endoscopic breast reconstruction procedures and applied it to our day surgery under the epidemic control of the novel coronavirus. The present study was a retrospective analysis. Patients who underwent unilateral breast endoscopic reconstruction surgery in the West China Hospital from April 2017 to February 2021 were included in the study. Patients were divided into the following three groups: ward exploration period (WEP), ward maturation period (WMP), and day surgery period (DSP), respectively. We compared the results of postoperative complications, hospitalization costs, operation time, and BREAST-Q (a patient-reported outcome instrument measuring health-related quality-of-life and patient satisfaction in breast surgery) scale scores among the three groups of patients. A total of 66 patients were included (WEP n=30, WMP n=14, DSP n=22). Four people refused to complete the BREAST-Q scale, and five patients missed complication record sheets. Patients in the DSP and WMP groups had slightly higher postoperative satisfaction with their breasts than WEP, but there was no statistically significant difference (3 months postoperatively: WEP vs. WMP =0.515, WEP vs. DSP =0.418, WMP vs. DSP =0.982). On the postoperative BREAST-Q scale scores of psychosocial, sexual life and chest well-being, patients with DSP scored slightly higher than those with WEP versus WMP, but there was no statistically significant difference. The incidence of postoperative complications was generally higher in the WEP group than in the WMP and DSP groups, but there was no statistically significant incidence of either major or minor complications (P=1.000). With the use of prostheses and mesh, patients in the DSP group had lower hospitalization costs than other two groups. In terms of operative time, patients in the WMP and DSP groups had shorter operative times compared with the WEP group, and the results were statistically significant (WEP vs. WMP =0.000, WEP vs. DSP =0.000, WMP vs. DSP =0.243). We believe that performing our newly developed endoscopic breast reconstructive surgery at a day surgery center is safe and reliable.

The utility of free abdominal flap without Zone 4 procedure for unilateral breast reconstruction.

The perfusion concept of free abdominal flap for breast reconstruction shares the common perception. We believed that free abdominal flap without Zone 4 could be performed. The purpose of this study is to introduce the "without Zone 4 procedure" and compare with the conventional technique (without 4 vs. conventional groups). The "without 4 group" included 61 patients, while the conventional group 55 patients. The inclusion criterion for the "without Zone 4 procedure" was defined as the thickest part of flap was more than half of the contralateral breast projection. The centerline of the skin island was adjusted to the position with the most medial side of the perforator. We compared basic characteristics (age, BMI, operation time, blood loss, contralateral breast size, smoking status, and history of laparotomy), the flaps' horizontal and vertical widths, thickness of the thickest part of the flap, elevated flap weight, and operative procedure. The mean length of the flaps' horizontal width was significantly shorter (19.2cm vs. 26.3 cm; p < .001) and the mean flap thickness was significantly greater in the without 4 group. The mean contralateral breast height and projection length were significantly longer in the conventional group. No significant differences were found with respect to the other characteristics. Patients with a lower breast projection compared with the abdominal fat thickness could undergo reconstruction with a shorter flap horizontal width. Because of the esthetic outcome of the donor site, this procedure is more appropriate for low-BMI patients.

6: ICG-Fluorescence Lymphography After Immediate Lymphatic Reconstruction

Purpose:Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in the development of breast-cancer associated lymphedema. However, questions remain regarding the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. The aim of our study is to assess lymphographic outcomes, including ICG pattern and LVB patency, following axillary ILR in patients at high risk for breast cancer associated lymphedema..Methods:Baseline ICG studies of 15 patients who underwent ILR were compared to studies obtained during secondary stage breast reconstructive procedures to assess for any changes in lymphatic morphology and transit in the at-risk arm.Results:All 15 patients in this study demonstrated linear lymphatic flow in intra-operative lymphography studies performed during the initial lymphatic reconstruction. An average of 2.4 (range 1-4) LVBs were performed per patient. Only 1 patient in this study group had preservation of in-continuity lymphatics at time of ALND. Followup lymphographic studies showed clear, linear lymphatic transit in 12/15 patients. Of these 12 patients, an average of 2.5 LVBs were performed, 10 received chemotherapy (7 neoadjuvant, 3 adjuvant), and all 12 received post mastectomy radiation (PMRT). Dermal backflow patterns of varying severity were recorded in 3/15 patients, two of whom showed signs of lymphedema prior to their followup study and the last went on to develop clinically detectable lymphedema. Of these 3 patients, an average of 2 LVBs were performed, all received chemotherapy (2 neoadjuvant, 1 adjuvant) and 2/3 underwent PMRT. Of the 12 patients that remain lymphedema-free, 7 post-operative studies demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla without evidence of lymphatic collateralization. An average of 3 LVBs were performed in this group and 100% of these patients received adjuvant radiation.Conclusion:We have demonstrated that ICG lymphography can be implemented as a post-operative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Post-operative imaging studies in the majority of patients demonstrated linear ICG flow with evidence of lymphatic contractility and velocity similar to baseline studies obtained at the time of lymphadenectomy and ILR. Additionally, ICG flow patterns through the axilla in post-operative imaging studies provided visual evidence supporting sustained LVB patency despite inflammation and tissue fibrosis associated with axillary irradiation.

Breast Reconstruction for Cancer Patients in COVID-19 Pandemic.

Breast reconstruction is considered an integral aspect of breast cancer treatment and has a well-known positive effect on quality of life. Surgical treatment of cancer has been delayed until evaluation of local circumstances of coronavirus disease of 2019 (COVID-19), adding to reasons why breast reconstruction procedures may have been delayed.1 In developing countries and middle-income economies, breast reconstruction has had a slow growth; even now, some countries do not cover breast reconstructive surgery, and we were just starting to see progress on the subject in recent years.2 We think breast reconstruction should not be abandoned as an important subject in benefits for cancer patients, even during this pandemic. At our institutions, we continue to offer breast reconstruction surgery, even during the COVID-19 pandemic (Fig. 1). To achieve this, we offer short-recovery surgical procedures to reduce patient exposure to coronavirus. We even try to favor a same-day surgery approach. This could mean direct-to-implant surgery when feasible or tissue expander placement when a second surgery would be required. We also look for options that reduce patient hospital stay, such as enhanced recovery after surgery protocols; combined anesthesia, with local blockades to reduce the effects of intravenous medications (e.g., nausea and vomiting) to favor shorter hospital stays; and oral intubation to contain aerosolization of virus for the protection of the surgical team.3 Immediate reconstruction will favor less exposure to coronavirus, avoiding at least one subsequent surgery and hospitalization.Fig. 1.: Proposed approach for breast reconstruction during the COVID-19 pandemic. DIEP, deep inferior epigastric perforator; SIEA, superficial inferior epigastric artery; SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator; PAP, profunda artery perforator; TUG, transverse upper gracilis.There have been reports of thrombosis complications secondary to coronavirus infection.4 In this scenario, microsurgery procedures could be delayed until we have more and better knowledge, or at least new data and evidence of perioperative complications in elective microsurgery procedures. When the possibility of radiation was present, or after a shared decision-making approach, we opted for microsurgical free flap reconstruction, a tissue expander would be a better option to delay flap surgery at least 6 months, so we can offer a better safety profile. Offering immediate lymphatic reconstruction would offer higher benefits in these circumstances, to avoid new surgical procedures when possible, in addition to its established benefits.5 Nowadays, coronavirus infection considerations should be part of the shared decision-making process, and first consultation could be performed through virtual online options and three-dimensional models, as well as some follow-up consultations. Breast reconstruction should be considered in breast cancer patients even during the actual COVID-19 pandemic, and time will tell which is the best approach. For now, we should be proactive with caution. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

The Impact of the COVID-19 Pandemic on Breast Reconstruction: A Canadian Perspective.

Background:The COVID-19 pandemic has led to unprecedented challenges and restrictions in surgical access across Canada, including for breast reconstructive services which are an integral component of comprehensive breast cancer care. We sought to determine how breast reconstructive services are being restricted, and what strategies may be employed to optimize the provision of breast reconstruction through a pan-Canadian evaluation from the providers’ perspective.Methods:This was a cross-sectional survey of Canadian plastic and reconstructive surgeons who perform breast reconstruction. The 33-item web-based questionnaire was developed by a pan-Canadian working group of breast reconstruction experts and disseminated via email to members of the Canadian Society of Plastic Surgery. The questionnaire queried respondents on the impact of the COVID-19 pandemic and associated restrictions on surgeons’ breast reconstruction practice patterns and opinions on strategies for resource utilization.Results:Responses were received from 49 surgeons, who reported practicing in 8 of 10 Canadian provinces. Restrictions on the provision of breast reconstructive procedures were most limited during the First Wave of the COVID-19 pandemic, where all respondents reported at least some reduction in capacity and more than a quarter reporting complete cessation. Average reported reduction in capacity ranged from 31% to 78% across all 3 waves. Autologous, delayed, and prophylactic reconstructions were most commonly restricted.Conclusion:This study provides a pan-Canadian impact assessment on breast reconstructive services during the COVID-19 pandemic from the providers’ perspective. To uphold the standards of patient-centred care, a unified approach to strategically reorganize health care delivery now and in the future is needed.

Free-flap breast reconstruction: cost analysis in the Swiss healthcare system

Breast cancer is the most common type of malignancy among women. Mastectomy maintains an essential role in oncological therapy and led to the development of breast reconstruction procedures. The deep inferior epigastric perforator (DIEP) free flap became in the last decade a popular approach for breast reconstruction. Although this procedure is known to be more complex than other techniques, it offers one of the highest patient satisfaction rates. However, the cost-effectiveness of this technique has rarely been assessed; and the real cost coverage by health insurance has never been studied. This study estimated the real cost of immediate DIEP free flap breast reconstruction after unilateral mastectomy and evaluated the cost coverage by healthcare insurers according to the diagnosis-related group (DRG) reimbursement scheme in Switzerland. Medical files of 20 consecutive patients who underwent immediate DIEP free-flap breast reconstruction between 2012 and 2017 were reviewed retrospectively. Billing data according to DRG rates were compared with an estimation of the real cost generated by the procedure. The mean charge according to the DRG model for one-stage DIEP free-flap reconstruction was CHF 29,573 (CHF 19,256–64,741). The mean real estimated cost was CHF 33,416 (CHF 20,633–47,036). Seven different DRG codes were used between 2012 and 2017, each offering a different definition and compensation. The DRG pricing scheme evolves through annual revisions. Progressively, more specific codes were created and used, allowing a better cost coverage for the procedure. Since 2017, the use of the dedicated code J01B has resulted in adequate cost coverage of the procedure. Since it has been widely accepted that DIEP breast reconstruction has advantages such as high patient satisfaction, we encourage the inclusion of this procedure in the reconstructive arsenal of breast cancer centres in Switzerland.