Conversion from Alloplastic to Autologous Breast Reconstruction: What Are the Inciting Factors?

Introduction: Failure of alloplastic breast reconstruction is an uncommon occurrence that may result in abandonment of reconstructive efforts or salvage with conversion to autologous reconstruction. The purpose of this study was to identify factors that predict failure of alloplastic breast reconstruction and conversion to autologous reconstruction. Methods: A retrospective chart review was conducted of patients who underwent mastectomy and immediate alloplastic breast reconstruction between 2008 and 2019. Inclusion criteria included patients 18 years or older who underwent initial alloplastic reconstruction with a minimum of 3-year follow-up. Data collected included age, body mass index, cancer type, surgical characteristics, neo/adjuvant treatment details, and complications. Results were analyzed using Fischer's exact test, t-test, and multivariate logistic regression. Results: A total of 234 patients met inclusion criteria. Of those, 23 (9.8%) required conversion from alloplastic to autologous reconstruction. Converted patients had a mean age of 50.1 ± 8.5. The time from initial alloplastic reconstruction to conversion was 30.7 months. The most common reasons for conversion included soft tissue deficiency (48%), infection (30%), and capsular contracture (22%). Patients were converted to deep inferior epigastric perforator flap (DIEP; 52%), latissimus dorsi flap with implant (26%), and DIEP with implant (22%). Multivariate logistic regression modeling identified radiation (OR 8.4 [CI = 1.7-40.1]) and periprosthetic infection (OR 14.6 [CI = 3.4-63.8]) as predictors for conversion. Conclusions: Among patients undergoing mastectomy with immediate alloplastic breast reconstruction, those treated with radiation have 8.4 greater odds of conversion and those with a periprosthetic infection have 14.6 greater odds for conversion to an autologous reconstruction.

Introduction : L'échec d'une reconstruction mammaire alloplastique est un événement peu fréquent qui peut aboutir à un abandon des efforts de reconstruction ou à une solution de secours avec une conversion en reconstruction autologue. L'objectif de cette étude était d'identifier les facteurs prédisant l'échec de la reconstruction mammaire alloplastique et sa conversion en reconstruction autologue. Méthodes : Une étude rétrospective a été menée sur les dossiers de patientes ayant subi une mastectomie suivie d'une reconstruction mammaire alloplastique immédiate entre 2008 et 2019. Les critères d'inclusion étaient notamment des patientes âgées d'au moins 18 ans ayant subi une reconstruction alloplastique initiale avec un suivi minimum de 3 ans. La collecte de données a inclus : l'âge, l'indice de masse corporelle (IMC), le type de cancer, les caractéristiques chirurgicales, les détails sur le traitement adjuvant/néoadjuvant et les complications. Les résultats ont été analysés à l'aide du test t exact de Fischer, un test t et une analyse de régression logistique multifactorielle. Résultats : Un total de 234 patientes a satisfait les critères d'inclusion. Parmi ces patientes, 23 (9,8%) ont nécessité la conversion de la reconstruction alloplastique en reconstruction autologue. Les patientes « converties ¼ avaient un âge moyen de 50,1 ± 8,5 ans. Le délai séparant la reconstruction alloplastique initiale et la conversion était de 30,7 mois. Les motifs les plus fréquents de conversion étaient une déficience des tissus mous (48%), une infection (30%) et la formation d'une coque (22%). Les techniques de conversion utilisées étaient la technique dite DIEP ou AEIP (artère épigastrique inférieure profonde, 52%), un lambeau du grand dorsal avec implant (26%), et la technique DIEP avec implant (22%). Une modélisation d'analyse de régression logistique multifactorielle a identifié les facteurs prédictifs de conversion suivants : irradiation (rapport de cotes = 8,4 [IC = 1,7-40,1]) et l'infection périprothétique (RC = 14,6 [IC = 3,4 à 63,8]). Conclusions : Parmi les patientes subissant une mastectomie avec reconstruction mammaire alloplastique immédiate, celles qui ont reçu une radiothérapie avaient un risque de conversion 8,4 fois plus grand et les patientes ayant une infection périprothétique avaient un risque 14,6 fois plus grand de conversion en reconstruction autologue.

Symmetric Breast Surgery: Balancing Procedures versus Prophylactic Mastectomy and Immediate Reconstruction.

BACKGROUND: Various techniques for management of the contralateral breast exist in patients with unilateral breast cancer, including contralateral prophylactic mastectomy with immediate breast reconstruction (PMIBR), and symmetrization techniques including augmentation, reduction, or mastopexy. The purpose of this prospective cohort study was to evaluate and compare complications and patient-reported satisfaction of patients with contralateral PMIBR versus having symmetrization procedures. METHODS: A 7-year, single-institution, prospectively maintained database was reviewed. Patient-reported BREAST-Q scores were obtained at baseline, 3 months, and 12 months prospectively. Postoperative complications, oncologic outcomes, and BREAST-Q scores were compared. RESULTS: A total of 249 patients were included, 93 (37%) of whom underwent contralateral PMIBR and 156 (63%) of whom underwent contralateral symmetrization. The patients who underwent PMIBR were younger and had less comorbidities compared with patients with symmetrization. Rates of major and minor complications were similar, apart from higher rates of minor wound dehiscence in the PMIBR group. When comparing mean change at 12-month follow-up to preoperative results, there was a significant decrease in physical well-being of the chest in the symmetrization compared with the PMIBR group (2.94 versus -5.69; P = 0.042). There were no significant differences in mean breast satisfaction and psychosocial well-being, and nonsignificant decreases in sexual well-being between groups. CONCLUSIONS: Patients with unilateral breast cancer who underwent immediate contralateral breast management, with either contralateral PMIBR or symmetrization techniques, demonstrated similar profiles of major complications and good overall satisfaction except for one physical well-being domain. Management of the contralateral breast with symmetrization may provide similar outcomes compared with PMIBR, which often is considered not necessary in patients without specific indications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patient-reported outcomes following free flap lower extremity reconstruction: A systematic review and meta-analysis.

PURPOSE: Free flap reconstruction in the lower extremity has shown success for the management of large and complex defects, restoration of function, and favorable aesthetic outcomes. Patient-reported outcomes (PROs) have not been well explored in previous literature. This meta-analysis aimed to provide a comprehensive summary of PROs after free flap reconstruction in the lower extremity. METHODS: We searched MEDLINE and Embase from 1946 to 2021 for studies reporting on PROs following free flap reconstruction in the lower extremity. RESULTS: Overall, 53 studies were included, and 11 studies reported validated PRO measures for meta-analysis. A total of 1953 patients underwent reconstruction with 1958 free flaps for lower limb defects with a mean follow-up of 3.26 (0.25-7.83) months. The mean postoperative Lower Extremity Functional Scale (LEFS) scores were 60.3 (±12) out of 80 points (4 studies, 85 patients). The mean postoperative AOFAS scores were 75.1 (±15) out of 100 points (4 studies, 68 patients). The mean postoperative SF-36 scores were 88.1 (±8.0) out of 100 points; mental health component was 48.7 (±8.9), and physical component was 38.4 (±8.2), out of 50 points (4 studies, 88 patients). CONCLUSION: Our findings demonstrated that patients report improved physical health, mental health, and function following lower extremity reconstruction with free flaps. Patients reported similar improvements in functional scores following lower extremity reconstruction regardless of their free flap type. Furthermore, patients with myocutaneous flaps may have improved mental health and worse physical health scores when compared to perforator flaps. The evidence profiles presented in this review indicate that additional research is needed to help guide future decision-making.

Free Functional Muscle Transfer following Upper Extremity Sarcoma Resection: A Case Report.

Functional reconstruction of the upper extremity has traditionally involved tendon transfer or pedicled muscle transfer. The gracilis free functional muscle transfer remains as an excellent option for restoration of finger flexion. Here, we provide a case report of a 35-year-old man diagnosed with left forearm high-grade epithelioid sarcoma who underwent innervated free gracilis transfer and a secondary free flap, the profunda artery perforator flap, through a single donor-site incision to expand soft tissue coverage. Postoperatively, there were no complications reported. At 8-month follow-up, the patient had Musculoskeletal Tumor Score of 22/30, and a Quick Disabilities of the Arm, Shoulder, and Hand score of 34/100.

Power-assisted Liposuction and a Single Incision Pull-through Technique for Top Surgery: A Case Report.

Various treatment approaches exist for female-to-male subcutaneous mastectomy, also known as "top surgery." The most commonly performed techniques for patients with decreased volume of breast tissue, no ptosis, and good skin elasticity continue to involve areolar or periareolar incision. Here, we report a case of a 17-year-old patient who underwent top surgery performed through power-assisted liposuction and a non-areolar single-incision "pull-through" technique. Operative management included initial liposuction for contouring of adipose tissue. Surgical subcision of excess breast tissue adherent to the subdermal plane was then performed and removed with a grasp-and-pull motion using the pull-through technique. We obtained a favorable result with low scar burden, preserved nipple sensation, and no nipple contracture. No complications were reported. This procedure is limited for patients with small breast size (A cup, <100 grams of glandular tissue per side), minimal to no ptosis, appropriate nipple size and position, soft fibroglandular tissue, and good skin elasticity.

Lipid-lowering therapy for primary prevention of premature atherosclerotic coronary artery disease: Eligibility, utilization, target achievement, and predictors of initiation.

OBJECTIVES: Despite advances in screening and prevention, rates of premature coronary artery disease (CAD) have been stagnant. The goals of this study were to investigate the barriers to early risk detection and preventive treatment in patients with premature CAD. In particular, we: 1) assessed the performance of the latest versions of major international guidelines in detection of risk of premature CAD and eligibility for preventive treatment; and, 2) investigated real-life utilization of primary prevention with lipid-lowering therapies in these patients. METHODS: We included patients in the Study to Avoid cardioVascular Events in British Columbia (SAVE BC), an observational study of patients with premature (males â€‹≤ â€‹50 years, females â€‹≤ â€‹55 years) angiographically confirmed CAD. Eligibility for primary prevention and treatment received were assessed retrospectively based on information recorded prior to or at the index presentation with CAD. RESULTS: Of 417 patients (28.1% females) who met the criteria, 94.3% had at least one major cardiovascular risk factor. In the retrospective risk assessment, 41.7%, 61.4%, and 34.3% (p â€‹< â€‹0.001) of patients met criteria for initiation of statin therapy, and an additional 13.9%, 8.4%, and 46.8% may be considered for treatment using the American College of Cardiology/American Heart Association, Canadian Cardiovascular Society, and European Society of Cardiology guidelines, respectively. Only 17.1% of patients received statins and 11.0% achieved guideline-recommended lipid goals before presentation. Diabetes and elevated plasma lipid levels were positively associated with treatment initiation, while smoking was associated with non-treatment. CONCLUSIONS: The current versions of major guidelines fail to recognize many patients who develop premature CAD as being at risk. The vast majority of these patients, including patients who have guideline-directed indications, do not receive lipid-lowering therapy before presenting with CAD. Our findings highlight the need for more effective screening and prevention strategies for premature CAD.