Seeking Breast Reconstruction Research Articles

A New Start with HAART: Evaluating Breast Reconstruction in the Era of Highly Active Antiretroviral Therapy.

As HIV-positive individuals utilizing highly active antiretroviral therapy live longer, the burden of breast cancer increases in the population. Breast reconstruction is an integral aspect of surgical treatment for many patients after a breast cancer diagnosis, prompting this examination of the characteristics and outcomes of breast reconstruction in this growing patient population. Using Merative MarketScan Research Databases, a large multipayer database, HIV-positive adult patients who underwent autologous or implant-based breast reconstruction between 2007 and 2021 were identified using International Classification of Disease codes and Common Procedural Terminology codes. In both HIV-positive and -negative cohorts, patient demographics, procedure-related complications, and postoperative revisions were recorded. Shapiro-Wilk, chi-square, Wilcoxon-Mann-Whitney, and multivariable logistic regression tests were used for statistical analysis. Of 173,421 patients who underwent breast reconstruction, 1816 had an HIV diagnosis. HIV-positive patients were younger (P < 0.001), underwent surgery more recently (P < 0.001), more often underwent immediate breast reconstruction (P < 0.001), and had higher comorbidity levels (P < 0.001). There was a regional variation in which the patient cohorts underwent breast reconstruction. There was no significant difference in overall complication rates between patient groups, but HIV-negative patients more often underwent revision procedures (P = 0.009). When compared to their HIV-negative counterparts, breast reconstruction can be considered safe and efficacious in patients living with HIV. HIV-positive patients are a growing demographic who seek breast reconstruction, and surgeons must continue to further understand the unique implications of breast reconstruction in this population.

Current Global Trends in Prepectoral Breast Reconstruction.

Implant-based breast reconstruction (IBBR) is the most frequently performed procedure for breast reconstruction following mastectomy, which involves the surgical placement of breast implants. The approach to breast reconstruction can be divided into two main categories, namely prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR), based on the implant plan and placement technique. In recent years, there has been a significant surge in the popularity of prepectoral implant-based breast reconstruction, where the implants are positioned above the chest muscle, as opposed to beneath it in the subpectoral approach. However, despite this growing preference, there is a lack of comprehensive data regarding the national trends in the utilization of this technique, thus necessitating further investigation. This narrative review aims to ascertain the current global patterns linked to prepectoral breast reconstruction and elucidate the considerations surrounding patient and implant selection, reconstructive techniques, the utilization of meshes in prepectoral reconstruction, the ensuing outcomes and complications, the ramifications of radiotherapy, and the potential advantages of integrating fat infiltration into the implementation of this technique in breast reconstruction with a focus on published papers in last five years. Conclusion: Prepectoral breast reconstruction has emerged as an appropriate surgical option for individuals seeking breast reconstruction. This development can be attributed to the recent progress made in implant technology, which has significantly enhanced the outcomes of this procedure. Additionally, advancements in mastectomy techniques, autologous fat grafting, and the use of acellular dermal matrices (ADMs) have also played a vital role in improving the aesthetic results of prepectoral breast reconstruction. As a result, the significance and effectiveness of this technique in the field of breast reconstruction have been firmly established, making it an essential component of the overall armamentarium available to plastic surgeons for breast reconstruction purposes.

Effect of Total Breast Reconstruction With Autologous Fat Transfer Using an Expansion Device vs Implants on Quality of Life Among Patients With Breast Cancer

There is a need for a new, less invasive breast reconstruction option for patients who undergo mastectomy in their breast cancer treatment. To investigate quality of life (QoL) among patients undergoing a new breast reconstruction technique, autologous fat transfer (AFT), compared with that among patients undergoing implant-based reconstruction (IBR). The BREAST trial was a randomized clinical trial conducted between November 2, 2015, and October 31, 2021, performed in 7 hospitals across the Netherlands. Follow-up was 12 months. Referrals could be obtained from general practitioners and all departments from participating or nonparticipating hospitals. The patients with breast cancer who had undergone mastectomy and were seeking breast reconstruction were screened for eligibility (radiotherapy history and physique) by participating plastic surgeons. Patients receiving postmastectomy radiotherapy were excluded. Breast reconstruction with AFT plus expansion or 2-phased IBR. Randomization was done in a 1:1 ratio. The statistical analysis was performed per protocol. The predefined primary outcome was QoL at 12 months after final surgery. This was measured by the BREAST-Q questionnaire, a validated breast reconstruction surgery questionnaire. Questions on the BREAST-Q questionnaire are scored from 0 to 100, with a higher score indicating greater satisfaction or better QoL (depending on the scale). Secondary outcomes were breast volume and the safety and efficacy of the techniques. A total of 193 female patients (mean [SD] age, 49.2 [10.6] years) 18 years or older who desired breast reconstruction were included, of whom 91 patients in the AFT group (mean [SD] age, 49.3 [10.3] years) and 80 in the IBR group (mean age, 49.1 [11.0] years) received the allocated intervention. In total, 64 women in the AFT group and 68 women in the IBR group completed follow-up. In the IBR group, 18 patients dropped out mainly due to their aversion to implant use while in the AFT group 6 patients ended their treatment prematurely because of the burden (that is, the treatment being too heavy or tiring). The BREAST-Q scores were higher in the AFT group in all 5 domains and significantly higher in 3: satisfaction with breasts (difference, 9.9; P = .002), physical well-being: chest (difference; 7.6; P = .007), and satisfaction with outcome (difference, 7.6; P = .04). Linear mixed-effects regression analysis showed that QoL change over time was dependent on the treatment group in favor of AFT. The mean (SD) breast volume achieved differed between the groups (AFT: 300.3 [111.4] mL; IBR: 384.1 [86.6] mL). No differences in oncological serious adverse events were found. This randomized clinical trial found higher QoL and an increase in QoL scores over time in the AFT group compared with the IBR group. No evidence was found that AFT was unsafe. This is encouraging news since it provides a third, less invasive reconstruction option for patients with breast cancer. ClinicalTrials.gov Identifier: NCT02339779.

Abstract ED6-3: How to reconcile novel reconstructive techniques with the need to radiate

Abstract The indication for postmastectomy radiotherapy (PMRT) is mainly based on tumor stage and the extent of lymph node involvement. The results of EBCTCG meta-analysis (EBCTCG Lancet, 2014) support the need of radiation therapy (RT) for patients with one to three axillary metastatic lymph nodes (LN), as well as for patients with &amp;gt; 3 affected LN. In nearly 40% of patients with mastectomy (ME) RT is required. According to the plastic surgery statistics report 2020 approximately 80% of patients seeking breast reconstruction in the USA receive an implant-based breast reconstruction (IBBR), while 18% undergo autologous reconstruction (ASoPS 2020). PMRT, regardless of reconstructive method, has been found to have a detrimental effect on outcomes with increased postoperative complications and decreased patient satisfaction. Nevertheless, even in this cohort the number of breast reconstruction (BR) is increasing over time. Surgical techniques for ME and BR are advancing constantly. With the increasing use of skin-sparing ME (SPM) techniques, particularly nipple-sparing ME (NSM), one stage IBBR (single-stage direct-to-implant, DTI) become more popular. With the availability of supportive materials such as synthetic/biological mesh or acellular dermal matrix (ADM) there has been a significant improvement in pre-pectoral implant reconstruction. The impact of PMRT on the outcomes of pre-pectoral IBRR has been recently summarized in a systemic review and meta-analysis by Awadeen (Aesth Plast Surg, 2022). Wound infection, capsular contraction and implant loss were significantly more frequent in the irradiated than in the non-irradiated breasts. Several studies describe the delayed/2-stage IBBR in the setting of PMRT as more promising and discuss different timings of exchange from expanders to implant. In one systematic review, PMRT to permanent implants reduced the rate of reconstructive failure compared to TE (J Surg Oncol,2015). After prosthetic-based BR and RT, conversion to autologous reconstruction can always be considered. Recommendations for immediate autologous reconstruction vary when PMRT is required. PMRT can result in wound complications, fat necrosis and volume loss, but overall cosmetic results are better than with IBBR and PMRT. When undergoing delayed reconstruction after PMRT, the optimal time from PMRT to reconstruction is unknown. In patients with a history of RT, NCCN-guidelines (V.4.2022) recommend autologous reconstruction as the preferred reconstruction option. Fat grafting, which can optimize tissue perfusion and wound healing, is playing an emerging role in breast surgery. Lipofilling can be used to improve the thickness of the mastectomy flap and to recontour breast defects after PMRT. There is an increasing awareness for better understanding of the different reconstruction types to define target volumes depending on the varying risk for residual tissue and potential recurrences. The ESTRO-ACROP guidelines discuss adapted dose distribution in accordance with the different locations of the implant (pre-or sub-pectoral) (Radiotherapy and Oncology, 2019). The risks and benefits of immediate versus delayed as well as implant-based versus autologous reconstruction must be considered for each individual patient and should be planned in a multidisciplinary setting, especially when PMRT is required. Citation Format: Christine Solbach. How to reconcile novel reconstructive techniques with the need to radiate [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr ED6-3.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

Background:Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity.Methods:A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services.Results:Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services.Conclusions:A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

OP2: Breast Reconstruction with a DIEP Flap in Elderly (&gt;60 Years) Patients

INTRODUCTION: Breast cancer is primarily a diagnosis of older women. Many patients seeking breast reconstruction are elderly women, aged over 60 years. Free tissue transfer carries the risk of perioperative morbidity and mortality in elderly patients. To clarify this issue we performed a comparative study. MATERIALS AND METHODS: A retrospective cohort study composed of chart review of all deep inferior epigastric perforator flap breast reconstruction patients at a single institution divided into an elderly cohort (60 years or older) and a non-elderly cohort (younger than 60 years). Demographic and comorbidity data were secondary predictor variables. Primary outcomes were complete flap loss, partial flap loss, or need for flap re-exploration. Secondary outcomes included surgical site occurrence, such as wound healing problems, seroma, and others. RESULTS: There were 173 flaps in the nonelderly cohort and 37 flaps in the elderly cohort. The elderly cohort had higher rates of diabetes, hypertension, and hyperlipidemia. Chi-square analysis showed no significant differences in primary outcomes between the two cohorts (1.1% vs 2.7%, p=0.459). Breast wound dehiscence was slightly higher in the elderly cohort (7.4% vs 5.4%, p=0.663). On logistic regression, being elderly was seen not as a significant risk factor for complete flap loss. The overall success rate for the nonelderly cohort was 97.3 percent, whereas the success rate for the nonelderly cohort was 98.7 percent. CONCLUSION: Elderly women desire breast reconstruction. Free flap breast reconstruction is a viable and safe procedure in these patients.

Is there any difference in perioperative characteristics or postoperative complications between overweight, normal-weight and obese patients in delayed DIEP reconstructions?

Increased number of overweight and obese women are seeking breast reconstruction. Studies have demonstrated that obese experience increased rates of complications, but less data is available considering overweight patients. We analyzed the impact of body mass index (BMI) on perioperative characteristics and complications in unilateral delayed deep inferior epigastric perforator flap (DIEP) reconstructions. The records of patients with DIEP reconstruction performed between 2014 and 2020, were retrospectively analyzed. Patients were categorized into obese (BMI ≥30), overweight (BMI 25.0–29.9), and normal-weight groups (BMI <25). Patient characteristics (age, comorbidity, radiation, abdominal surgery, ASA category, and smoking), perioperative characteristics (length of operation, blood loss, vasoactive drugs, fluid administration, and urine output), and postoperative complications were recorded. The study included 308 patients. Of these, 104 (34%) were normal-weighted, 142 (46%) overweight and 62 (20%) obese. Among patients with BMI ≥ 25, blood loss increased (p = 0.002) and the length of operation tended to be longer (p = 0.072). No between-groups difference existed in fluid administration (p = 0.319), urine output (p = 0.425), or use of vasoactive drugs (p = 0.815). There was no statistically significant difference in overall complications (p = 0.122) between BMI groups. Blood loss >150ml was associated with both minor and major complications (p = 0.022). Greater BMI moderated with the radiation therapy for higher risk of minor complications (OR 42.0, 95%CI 3.54–49.7, p = 0.003). We conclude that greater BMI alone is not associated with a higher overall complication rate, but both overweight and obesity may be moderators for other risk factors.

Decision aid for women with newly diagnosed breast cancer seeking breast reconstruction surgery: A prospective, randomized, controlled, single-blinded, pilot study

Women undergoing immediate breast reconstruction for breast cancer often experience anxiety when faced with reconstruction and the type of reconstruction to choose. The purpose of this study is to analyze the impact of a decision aid on decisional conflict in women with newly diagnosed breast cancer seeking breast reconstruction.Newly diagnosed breast cancer patients seeking breast reconstruction at a single center were prospectively randomized into two groups. Comparisons were made between two groups using the decisional conflict scale (DCS): women who reviewed the standard educational materials prior to initial consultation (control) and women who reviewed standard materials prior to initial consultation and then reviewed a decision aid brochure at initial consultation and two-week post-consultation (intervention). Pre-to-post-consultation DCS scores were compared within and between the control groups and intervention groups to assess which group had lower DCS scores.A total of 20 patients, mean age 53±9 years were included. Median differences between pre-to-post-consultation DCS total scores in the control and intervention groups lowered from 32 to 22 and 28 to 16, respectively. Significant differences in subscores were control group: uncertainty: 54-21 (p = 0.030), and intervention group: uncertainty: 46-29 (p = 0.036) and values clarity: 29-25(p = 0.042). Pre-to-post-consultation differences between DCS scores and subscores did not demonstrate any statistical significance.Decision aids did not significantly reduce pre-operative DCS total scores compared to current educational materials. More educational materials may not always be helpful for patients.

Early postoperative outcomes in implant, pedicled, and free flap reconstruction for breast cancer: an analysis of 23,834 patients from the ACS-NSQIP datasets.

Many patients seek breast reconstruction following mastectomy. Debate exists regarding the best reconstructive option. The authors evaluate outcomes comparing implant, free flap, and pedicled flap reconstruction. Patients undergoing implant, pedicled flap, and free flap reconstruction were identified in the 2011-2016 NSQIP database. Demographics were analyzed and covariates were balanced using overlap propensity score. Logistic regression was used for binary outcomes and Gamma GLM for length of stay (LOS). Of 23,834 patients, 87.7% underwent implant, 8.1% free flap, and 4.2% pedicled flap reconstruction. The implant group had the lowest mean operative time (206min, SD 85.6). Implant patients had less pneumonia (OR 0.09, CI 0.02-0.36, p < 0.01), return to operating room (OR 0.62, CI 0.50-0.75, p < 0.01), venous thromboembolism (VTE) (OR 0.33, CI 0.14-0.79, p = 0.01), postoperative bleeding (OR 0.10, CI 0.06-0.15, p < 0.01), and urinary tract infections (UTI) (OR 0.21, CI 0.07-0.58, p < 0.01) than free flap patients. Pedicled flap patients had less postoperative bleeding (OR 0.69, CI 0.49-0.96, p = 0.03) than free flap patients. Pedicled flap patients had more superficial surgical site infections (p = 0.03), pneumonia (p = 0.02), postoperative bleeding (p < 0.01), VTE (p = 0.04), sepsis (p = 0.05), and unplanned reintubation (p = 0.01) than implant patients. Implant patients had the lowest LOS (1.6days, p < 0.01). Implant reconstruction has less short-term postoperative complications than free flaps and pedicled flap reconstructions. The overall complication rate among all reconstructive modalities remains acceptably low and patients should be informed of all surgical options.

An Innovative Autologous Breast Reconstruction Option: Musculo-derma-glandular, Axio-perforator, Bipedicled Flap.

Following a mastectomy, patients frequently seek breast reconstruction. Although there are several options for reconstruction, none of them are considered ideal. Taking patients' psychological and physical condition into account, we created a new flap technique with a low postoperative morbidity and short operation time. We harvested the flap composed of skin, breast tissue, and pectoralis major muscle with a base in the parasternal line from the contralateral breast. To display our results, we presented 2 case examples. The mean follow-up was 12 months, and no postoperative complications were observed. At follow-ups, patients answered the question, "How satisfied are you with the results of the surgery?" using a 5-point Likert-like scale (5, very satisfied; 4, somewhat satisfied; 3, undecided; 2, somewhat dissatisfied; and 1, very dissatisfied). The mean score was 4. Our study showed that this surgical approach is a safe and cost-effective alternative for immediate and delayed breast reconstruction.

Dr Patricia Clugston-A Spirit of Determination.

Dr Patricia Clugston was a British Columbia native who completed her plastic surgery residency training in Vancouver in 1993 before pursuing a fellowship in Nashville with Dr Patrick Maxwell in 1994. When Dr Clugston returned to Vancouver, she helped to establish a comprehensive and renowned breast reconstruction program. She spent her career advocating for and working towards better treatment options for women seeking breast reconstruction. As a determined surgeon and accomplished athlete, Dr Clugston was truly a tour de force in all aspects of her life. Patty, as she was affectionately known by her colleagues, loved her job. Dr Clugston was an avid advocate for medical education and an outstanding clinical researcher and speaker that established her as a shining star in Canadian plastic surgery. Patty had always lived life to the fullest and was determined that scleroderma would not change this. Her sharp wit, intellectual curiosity, and pragmatism masked an incredible courage as she fought bravely against a cruel disease. Dr Clugston died on March 1, 2005, at the age of 46 surrounded by the loving company of her husband, friends, and family at the Vancouver General Hospital. The Dr Patricia Clugston Chair in Breast Reconstruction was established in her name to honour her legacy and continue to improve the care of patients with breast cancer.

Abstract 14: Decision Aid For Women With Newly Diagnosed Breast Cancer Seeking Breast Reconstruction Surgery: A Prospective, Randomized, Controlled, Single-blinded, Pilot Study

Purpose: Women undergoing immediate mastectomy for breast cancer often experience anxiety when faced with breast reconstruction and the type of reconstruction to choose. The purpose of this study is to analyze the impact of a decision aid on decisional conflict in women with newly diagnosed breast cancer seeking breast reconstruction. Methods: Thirty-three newly diagnosed breast cancer patients seeking breast reconstruction at a single-center were prospectively randomized into two groups. Comparisons were made between two groups using the Decisional Conflict Scale (DCS): women who reviewed the standard educational materials prior to initial consultation (control) and women who reviewed standard materials prior to initial consultation and then reviewed a decision aid brochure at initial consultation and two weeks post-consultation (intervention). Differences between pre-to-post-consultation DCS scores, and DCS scores two weeks post-consultation in the control groups and intervention groups were compared to assess which group had lower DCS scores. Results: A total of 20 patients, mean age 53±9 years were included. Median differences between pre-to-post-consultation DCS Total scores in the control and intervention groups lowered from 32 to 22 and 28 to 16, respectively. Significant differences in subscores were control group: Uncertainty: 54 to 21 (p=0.030), and intervention group: Uncertainty: 46 to 29(p=0.036) and Values clarity: 29 to 25 (p=0.042). Differences between DCS scores and subscores two weeks post-consultation did not demonstrate statistical significance. Conclusions: Decision aids did not significantly reduce pre-operative DCS scores compared to current educational materials. Patients receiving the decision aid felt they clearly understood what reconstruction option meant most to them prior to surgery.

Psychosocial well-being at time of diagnosis of breast cancer affects the decision whether or not to undergo breast reconstruction

ObjectivesNumerous studies have shown that breast reconstruction after mastectomy improves QoL in breast cancer survivors. However, still about half of the patients does not opt for reconstruction. In order to accommodate suitable counseling, we should elucidate the factors that play a role in the decision-making process. This study aimed to evaluate the influence of QoL, among women diagnosed with breast cancer before the start of any treatment, on their decision whether or not to undergo breast reconstruction. Materials and methodsBREAST-Q surveys were provided to breast cancer patients at the specialized breast care outpatient clinic after their first consultation with a surgical oncologist, between June 2017 and March 2019. The Q-scores of the subdomains physical well-being, psychosocial well-being, sexual well-being, and satisfaction with breasts of patients that underwent mastectomy were statistically analyzed. ResultsSixty-seven patients, undergoing mastectomy, completed the questionnaire. Fifty-four percent received reconstructive surgery. Mean age of patients seeking breast reconstruction was significantly lower than patients who did not opt for a reconstruction (53.5 vs. 63.7). Mean follow-up after mastectomy was 18.1 months. Except for satisfaction with breasts, mean Q-scores were higher in the group of patients who did not choose for reconstructive surgery. Psychosocial well-being was significantly higher in the non-reconstruction group (p = 0.012). ConclusionsPsychosocial well-being at time of diagnosis of breast cancer was significantly higher in patients refraining from breast reconstructive surgery after mastectomy. Psychosocial characteristics might be essential for the decision-making process as well. Further prospective research should evaluate this.

Microsurgical Breast Reconstruction in the Obese Patient Using Abdominal Flaps: Complication Profile and Patient Satisfaction.

The obesity epidemic has led to larger numbers of obese patients seeking breast reconstruction. The aim of this study was to compare complication rates and patient satisfaction between obese and nonobese women undergoing autologous breast reconstruction using abdominal free flaps. The records of all patients who underwent microsurgical breast reconstruction by one surgeon for 15 years were reviewed. Patients were divided into obese (body mass index [BMI] ≥ 30 kg/m and nonobese groups. Demographic data, medical and smoking history, cancer type and treatments, surgical details, and complications were recorded. Breast-Q surveys were mailed to all patients, and satisfaction ratings were compared between obese and nonobese patients. There were 109 patients and 149 breast reconstructions, with a mean age of 49 years. Follow-up ranged from 6 to 112 months (median = 19 months). There were 59 patients in the obese group and 52 in the nonobese group. The 2 groups did not differ significantly in median age, follow-up, pathology type, presence of chemotherapy or radiation, or smoking history. Obese group had a higher incidence of mastectomy flap necrosis (19.3% vs 7.7%, P < 0.01) and a higher rate of unplanned reoperations (38.6% vs 21.1%, P < 0.01). Obesity was not associated with a higher risk of microsurgical complications or flap loss (7.0% vs 3.8%, P = 0.21). Overall wound complications did not differ between the groups, but the obese group had a higher rate of severe wound complications requiring operative intervention (15.8% vs 3.8%, P < 0.01). The obese group had a higher incidence of hernia or bulge (10.5% vs 0%, P = 0.03). Thirty-three patients returned completed surveys (response rate of 30%). There was no statistically significant difference in any Breast-Q category associated with BMI. Obesity was associated with higher rates of wound complications, reoperation, and abdominal bulge after microsurgical breast reconstruction. However, patient satisfaction remained high. Patients should be counseled regarding their relative risks, but high BMI should not be considered an absolute contraindication for microsurgical breast reconstruction.

Microsurgical Breast Reconstruction in the Obese: A Better Option Than Tissue Expander/Implant Reconstruction?

Obesity has reached epidemic proportions, with 72 million people in the United States classified as obese in 2010. This significant increase in obese patients is reflected in the breast cancer population seeking breast reconstruction. Previous studies demonstrated increased complication rates and decreased satisfaction in obese patients undergoing breast reconstruction. This study aims to directly compare prosthetic and autologous reconstruction in the obese population by evaluating surgical outcomes and patient satisfaction. In an institutional review board-approved study, a retrospective chart review was conducted on patients with a body mass index of 30.0 kg/m or greater who underwent breast cancer reconstruction after mastectomy with either free tissue transfer from the abdomen or prosthetic reconstruction over a 3-year period. The authors identified 96 patients with 141 reconstructions. Demographic, intraoperative, and postoperative variables were collected. All patients were sent the BREAST-Q questionnaire by means of mail to study the impact and effectiveness of breast surgery from the patient's perspective. Statistical analysis was completed with Fisher's exact test, Mantel-Haenszel chi-square test, Pearson chi square test, or Mann-Whitney-Wilcoxon test. Prosthetic-based breast reconstruction was associated with increased major breast complications (p < 0.001), mastectomy skin flap necrosis (p = 0.009), infection (0.006), and overall reconstructive failure (p < 0.0001) compared with autologous reconstruction. When evaluating the results of the BREAST-Q studies, the autologous reconstruction group had improved satisfaction with breasts (p < 0.0001), satisfaction with outcome (p = 0.01), psychosocial well-being (p = 0.007), and sexual well-being (p = 0.006). In the obese population, reconstruction with free tissue transfer from the abdomen resulted in decreased complications of the breast reconstruction site and improved patient satisfaction with outcomes compared with prosthetic reconstruction. Therapeutic, III.

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes.

To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient's characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the outcomes of a prospective longitudinal study on DIEP flap insetting and present an algorithm for reconstruction. Over 4 years, 70 consecutive immediate unilateral DIEP flap breast reconstructions were prospectively evaluated. DIEP insetting was based on the characteristics of the donor site and contralateral breast, according to the authors' algorithm. Baseline and outcome data were collected. Aesthetic outcomes were evaluated by a panel of three independent assessors, and patient-reported outcomes were quantified using the BREAST-Q at 1 year after reconstruction. Seventy women underwent reconstruction. There were no total or partial flap failures, four cases of fat necrosis, and 14 revision operations. Women reported a mean overall BREAST-Q score of 82 of 100, representing excellent satisfaction but poor satisfaction with sexual well-being. BREAST-Q scores were not associated with age or body mass index. Fat necrosis reduced satisfaction with the chest (absolute mean reduction, 13; 95 percent CI, 8 to 18; p = 0.002). Independent assessors scored the outcomes favorably, but there was no agreement between surgeons, nurses, and lay assessors. The authors' algorithm can support surgeons in selecting individually tailored DIEP flap insetting to achieve excellent aesthetic outcomes. Further research is needed as to the relevance of scores from BREAST-Q in relation to interventions. Therapeutic, IV.

Pre-operative predictive estimation of abdominal flap volume for breast reconstruction using ultrasound and an anthropometric method

The abdominal flap has proven to be an optimal autologous option for breast reconstruction. However, the feasibility of breast reconstruction using an abdominal flap should be determined pre-operatively, especially in lean patients. In order to achieve optimal symmetry when using an abdominal flap for breast reconstruction, a specific amount of abdominal tissue is required and this should be estimated prior to surgery. Patients with unilateral modified radical mastectomies requesting delayed breast reconstruction had their abdominal flap volume measured pre-operatively using a measuring tape and ultrasound. Contralateral breast volume was also measured using magnetic resonance imaging and was compared to the abdominal flap volume. Additionally, body mass index was measured for every patient. A correlation between each patient’s body mass index, contralateral breast volume, and abdominal flap volume was calculated. Twenty patients with a mean age of 39 years (range 26–49 years, SD 6) and a mean body mass index of 29 (range 23–35, SD 4) were included in this study. The mean breast volume was 620 cm3, and the mean abdominal flap volume was 770 cm3 (excluding zone IV). The mean breast volume to abdominal flap volume ratio (without zone IV) was 0.8. Our pre-operative measurements of breast volume, abdominal flap volume, and body mass index enabled us to establish a relationship between these variables and to determine the feasibility of surgery and the need for additional volume enhancement and breast symmetrization procedures in patients seeking breast reconstruction. Level of Evidence: Level IV, risk/prognostic study.

Impact of Obesity on Outcomes in Breast Reconstruction: A Systematic Review and Meta-Analysis.

Increased rates of both breast cancer and obesity have resulted in more obese women seeking breast reconstruction. Studies demonstrate that these women are at increased risk for perioperative complications. A systematic review was conducted to assess the outcomes in obese women who underwent breast reconstruction following mastectomy. Cochrane, PUBMED, and EMBASE electronic databases were screened and data were extracted from included studies. The clinical outcomes assessed were surgical complications, medical complications, length of postoperative hospital stay, reoperation rate, and patient satisfaction. Out of 33 studies met the inclusion criteria for the review and 29 provided enough data to be included in the meta-analysis (71,368 patients, 20,061 of whom were obese). Obese women (body mass index > 30 kg/m2) were 2.29 times more likely to experience surgical complications (95% confidence interval (CI) 2.19-2.39; p < 0.00001), 2.89 times more likely to have medical complications (95% CI 2.50-3.35; p < 0.00001), and had a 1.91 times higher risk of reoperation (95% CI 1.75-2.07; p < 0.00001). The most common complication, wound dehiscence, was 2.51 times more likely in obese women (95% CI 1.80-3.52; p < 0.00001). Sensitivity analysis confirmed that obese women were more likely to experience surgical complications (risk ratio 2.36, 95% CI 2.22-2.52; p < 0.00001). This study provides evidence that obesity increases the risk of complications in both implant-based and autologous reconstruction. Additional prospective and observational studies are needed to determine if the weight reduction prior to reconstruction reduces the perioperative risks associated with obesity.

Combining Autologous Breast Reconstruction and Vascularized Lymph Node Transfer.

Breast cancer patients are at risk for developing postmastectomy lymphedema syndrome of the ipsilateral upper extremity following treatment for breast cancer in the setting of an axillary dissection, postoperative radiation, and chemotherapy. For patients suffering from lymphedema who are also seeking breast reconstruction, combining an autologous abdominal free flap with a vascularized inguinal lymph node transfer provides patients the opportunity to have an aesthetic breast reconstruction as well as the potential to improve their lymphedema in a single operation. The present article aims to provide a description of the salient features of this approach including the preoperative preparation, the surgical technique, the postoperative management and complications, and a summary of the outcomes.

Impact of Obesity on Outcomes in Breast Reconstruction: A Systematic Review and Meta-Analysis

Given the continuous rise in obesity and breast cancer incidence, more obese women are seeking breast reconstruction. Studies demonstrate that these women are at increased risk for perioperative complications. A systematic review was conducted to assess the outcomes in obese women who have undergone breast reconstruction after mastectomy.