Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction.

INTRODUCTION: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. METHODS: A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. RESULTS: Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. CONCLUSIONS: Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.

Outcomes of Immediate Alloplastic Breast Reconstruction in Patients Receiving Post-Mastectomy Radiotherapy.

Background: Immediate alloplastic breast reconstruction is traditionally avoided in patients who require post-mastectomy radiation therapy (PMRT). However, a subset of patients who undergo alloplastic reconstruction may unpredictably require adjuvant radiation. The purpose of this study was to compare outcomes and complications in patients at our institution who had undergone immediate alloplastic breast reconstruction and received PMRT to either the permanent implant or temporary tissue expander. Materials and Methods: A retrospective cohort study was performed looking at patients who underwent immediate alloplastic breast reconstruction over a 10-year period (2009-2019) at our regional breast centre. All patients who underwent immediate alloplastic breast reconstruction and had PMRT were included in the study. Major (wound dehiscence with device exposure, or reconstructive failure) and minor (infection, capsular contracture, revision surgery) complication rates between those patients receiving radiation to a tissue expander versus implant were compared using Fisher exact test (P < .05). Results: Six-hundred ninety-two patients were identified, and 43 patients met inclusion criteria. Of this group, 29 received PMRT to implants and 14 received PMRT to tissue expanders. Complication rates were similar between groups for superficial wound infection (3.4% vs 7.1%), periprosthetic infection (3.4% vs 7.1%), capsular contracture (41.4% vs 21.4%), revision surgery for aesthetics (41.4% vs 21.4%), wound dehiscence and device exposure (3.4% vs 21.3%), and reconstructive failure (10.3% vs 6.7%). Total complication rates were similar between groups (51.7% vs 42.9%). Discussion: Overall 6.4% of patients who underwent immediate alloplastic breast reconstruction required PMRT over a 10-year period. Complication rates for infection, capsular contracture, revision surgery, wound dehiscence and device exposure, and reconstructive failure were similar between both groups. Total complication rates were similar between groups. This information will help to inform decision-making regarding immediate alloplastic reconstruction and expected complications when PMRT is needed.

Historique: D'habitude, on évite la reconstruction mammaire alloplastique immédiate chez les patientes qui ont besoin d'une radiothérapie après la mastectomie (RTAM). Toutefois, un sous-groupe de patientes peut avoir besoin de radiation adjuvante non planifiée. La présente étude visait à comparer les résultats cliniques et les complications chez les patientes de l'établissement des chercheurs, après une reconstruction mammaire alloplastique immédiate et une RTAM sur l'implant permanent ou les expanseurs tissulaires permanents. Matériaux et méthodologie: Les chercheurs ont procédé à une étude de cohorte rétrospective sur une période de dix ans (2009 à 2019) auprès de patientes qui avaient subi une reconstruction mammaire alloplastique immédiate à leur centre régional de traitement du cancer du sein. Toutes les patientes qui avaient subi une telle reconstruction et une RTAM en ont fait partie. Au moyen du test exact de Fisher (p < 0,05), les chercheurs ont comparé les complications majeures (déhiscence des plaies et exposition du dispositif ou échec de la reconstruction) et mineures (infection, contracture capsulaire, chirurgie de reprise) entre les patientes recevant une radiation sur les expanseurs tissulaires et sur l'implant, respectivement. Résultats: Les chercheurs ont extrait 692 patientes, dont 43 respectaient les critères d'inclusion. De ce groupe, 29 ont reçu une RTAM sur les implants et 14, sur les expanseurs tissulaires. Le taux de complication était semblable entre les groupes pour ce qui était de l'infection superficielle de la plaie (3,4 % par rapport à 7,1 %), de l'infection périprosthétique (3,4 % par rapport à 7,1 %), de la contracture capsulaire (41,4 % par rapport à 21,4 %), de la reprise de l'intervention pour des raisons esthétiques (41,4 % par rapport à 21,4 %), de la déhiscence de la plaie et de l'exposition du dispositif (3,4 % par rapport à 21,3 %) et de l'échec de la reconstruction (10,3 % par rapport à 6,7 %). Le taux total de complications était semblable entre les groupes (51,7 % par rapport à 42,9 %). Discussion: Dans l'ensemble, 6,4 % des patients qui ont subi une reconstruction mammaire alloplastique immédiate ont eu besoin d'une RTAM sur une période de dix ans. Le taux de complications d'infection, de contracture capsulaire, de chirurgie de reprise, de déhiscence de la plaie, d'exposition du dispositif et d'échec de la reconstruction était semblable dans les deux groupes, de même que le taux total de complications. Ces données contribueront à éclairer la décision de procéder à une reconstruction alloplastique immédiate et à évaluer les complications possibles en cas de RTAM.

Adherence of Burn Outpatient Clinic Referrals to ABA Criteria in a Tertiary Center: Creating Unnecessary Referrals?

Initial assessment and triage of burns are guided by the American Burn Association criteria for referral to a burn center. These criteria are sensitive but not specific and can potentially lead to over-triage and "unnecessary" clinic visits. We are a Level 1 trauma center with burn subspecialty care, and due to the COVID-19 pandemic, referrals to our multidisciplinary outpatient burn clinic required triaging for virtual care appointments. In order to improve the triage process, we retrospectively reviewed our outpatient burn clinic referrals over a 2-year period, 2018 to 2019, for adherence to American Burn Association criteria. We collected data pertaining to patient and burn characteristics, as well as treatment outcome, to characterize referrals not requiring an in-person appointment. Of the 244 patients referred, 73% met the referral criteria, with 45% of these patients being healed at the first visit and 14.6% requiring surgical management. Mean time from injury to first visit was 9.7 days (mode 6), and the average number of visits was 2. Overall, mean burn size was 2%, with the majority of injuries being partial thickness (71%), located in the hand or extremity (77%). There was a fairly equal distribution of contact (36%), flame (21%), and scald (26%) burns. This study highlights the nonspecific nature of the American Burn Association referral criteria. We found that pediatric and hand burns in particular were over-triaged and lead to "unnecessary" appointments. This information is useful to help adjust referral criteria and to guide triaging of appointments with the evolution of telehealth and virtual care.

Redefining postmastectomy radiation contouring in the era of immediate breast reconstruction: An accurate assessment of local recurrence risk.

INTRODUCTION: Most studies report post-mastectomy local recurrences as chest wall recurrences without clarifying whether the recurrence is in the subcutaneous tissue, muscle or underlying rib. Post-mastectomy chest wall radiation is recommended in patients at increased risk of locoregional recurrence. Chest wall radiation-related fibrosis has become an important clinical consideration in the era of immediate implant-based breast reconstruction. In patients with commonly performed subpectoral implant-based reconstruction, the pectoralis major becomes relocated anterior to the implant and just deep to skin, therefore raising the question of value in radiating deep chest wall structures. This study assessed the rate of recurrence in each anatomical region of chest wall in post-mastectomy patients. METHODS: A comprehensive breast cancer database of 4287 patients at a single regional cancer center from 2006 to 2018 was retrospectively analyzed to identify 1571 mastectomy patients. Recurrences were classified as local skin/subcutaneous, pectoralis muscle (pectoralis major), deep chest wall (pectoralis minor, intercostal muscle or rib) or regional axillary recurrence. RESULTS: A total of 26 patients with locoregional recurrence were identified. Most recurrences were in the skin/subcutaneous level. Of 1571 mastectomy patients, only one patient developed a local recurrence posterior to pectoralis major. Our literature search and meta-analysis revealed that local recurrences post-mastectomy are much more likely to be in subcutaneous tissues/pectoralis major versus deeper chest wall. CONCLUSION: A reduced clinical target volume which encompasses skin/subcutaneous and pectoralis muscle layers without treating deep chest wall may be more appropriate to reduce radiation-associated toxicity since avoiding circumferential radiation of an implant may prevent capsular contracture without compromising treatment benefit.

Creating a Favorable Microenvironment for Fat Grafting in a Novel Model of Radiation-Induced Mammary Fat Pad Fibrosis.

BACKGROUND: Radiofibrosis of breast tissue compromises breast reconstruction by interfering with tissue viability and healing. Autologous fat transfer may reduce radiotherapy-related tissue injury, but graft survival is compromised by the fibrotic microenvironment. Elevated expression of receptor for hyaluronan-mediated motility (RHAMM; also known as hyaluronan-mediated motility receptor, or HMMR) in wounds decreases adipogenesis and increases fibrosis. The authors therefore developed RHAMM peptide mimetics to block RHAMM profibrotic signaling following radiation. They propose that this blocking peptide will decrease radiofibrosis and establish a microenvironment favoring adipose-derived stem cell survival using a rat mammary fat pad model. METHODS: Rat mammary fat pads underwent a one-time radiation dose of 26 Gy. Irradiated (n = 10) and nonirradiated (n = 10) fat pads received a single intramammary injection of a sham injection or peptide NPI-110. Skin changes were examined clinically. Mammary fat pad tissue was processed for fibrotic and adipogenic markers using quantitative polymerase chain reaction and immunohistochemical analysis. RESULTS: Clinical assessments and molecular analysis confirmed radiation-induced acute skin changes and radiation-induced fibrosis in rat mammary fat pads. Peptide treatment reduced fibrosis, as detected by polarized microscopy of picrosirius red staining, increased collagen ratio of 3:1, reduced expression of collagen-1 crosslinking enzymes lysyl-oxidase, transglutaminase 2, and transforming growth factor ß1 protein, and increased adiponectin, an antifibrotic adipokine. RHAMM was expressed in stromal cell subsets and was downregulated by the RHAMM peptide mimetic. CONCLUSION: Results from this study predict that blocking RHAMM function in stromal cell subsets can provide a postradiotherapy microenvironment more suitable for fat grafting and breast reconstruction.

A cost-effectiveness analysis of DIEP vs free MS-TRAM flap for microsurgical breast reconstruction.

BACKGROUND AND OBJECTIVES: The deep inferior epigastric perforator (DIEP) flap may be associated with less long-term donor-site morbidity compared with free muscle-sparing transverse rectus abdominis myocutaneous flap (MS-TRAM) flap. However, DIEP flaps may have longer operative time and higher rates of acute postoperative complications. We performed a cost-effectiveness analysis (CEA) that compared the long-term costs and patient-reported outcomes between the two flaps. METHODS: A retrospective cohort of women who received free MS-TRAM or DIEP flap reconstruction between January 2008 and December 2012, with a minimum of 2-year follow-up, were recruited. Cost data of the primary reconstruction and any subsequent hospitalization due to complications from the reconstruction within 2 years were obtained. Each patient received a BREAST-Q questionnaire at 2 years post-reconstruction. RESULTS: In total, 227 patients (180 DIEP, 47 free MS-TRAM) were included. DIEP patients had significantly fewer abdominal hernia (P = 0.04). The adjusted-incremental cost-effectiveness ratios found that DIEP flap was more cost-effective to free MS-TRAM flap in the domains of "Physical Well-Being of the Abdomen" and "Satisfaction with Outcome." CONCLUSIONS: DIEP flap is the more cost-effective method of autologous breast reconstruction in the long-term compared with free MS-TRAM flap with respect to patient-reported abdominal well-being and overall satisfaction with the outcome.

Characterizing the lateral slope of the aging female eyebrow.

BACKGROUND: Ideal eyebrow aesthetics give a framework for brow rejuvenation and surgical procedures do not always provide satisfying results. Previous studies have shown elevation of the medial brow with aging; however, they failed to characterize overall shape changes. OBJECTIVE: To characterize changes in eyebrow slope with increasing age to better direct brow rejuvenation. METHODS: From standardized anteroposterior facial photographs of 100 women 20 to 80 years of age, eyebrow height was measured at the medial limbus and arch apex from a mid-pupillary horizontal. The slope of the eyebrow was calculated. Using group analysis, mean height and slope were compared using the Mann-Whitney U test. Regression analysis was used to determine the relationship between slope and age. RESULTS: Mean slope significantly decreased from 20 to 29 years of age to 40 to 49 years of age (0.22 versus 0.12; P=0.03), and then increased between 40 and 49 years of age and ≥60 years of age (0.12 versus 0.21; P=0.05). Medial height did not change significantly, and arch apex significantly decreased between 20 and 29 years of age and 40 and 49 years of age. Regression analysis showed a quadratic relationship between age and slope, with the decrease in slope until the fifth decade of life being directly related to increasing age. After this, age was not a significant contributor to slope changes. CONCLUSIONS: With increasing age, the slope of the eyebrow decreases until the fifth decade dependent on age. After the fifth decade, age no longer plays a significant role. Therefore, choice of brow lift technique should be carefully selected.

HISTORIQUE: Une esthétique idéale du sourcil fournit un cadre pour rajeunir le front, mais les interventions chirurgicales ne donnent pas toujours des résultats satisfaisants. Des études antérieures ont démontré une élévation de la partie médiale du front avec le vieillissement, mais n'ont pas caractérisé les changements de forme globaux. OBJECTIF: Caractériser les changements de la courbe des sourcils avec l'âge, afin de mieux orienter le rajeunissement du front. MÉTHODOLOGIE: À partir de photographies faciales antéroposté-rieures normalisées de 100 femmes de 20 à 80 ans, les chercheurs ont mesuré la hauteur des sourcils par rapport au limbe médial et à l'apex de l'arche à partir du milieu de la pupille horizontale. Ils ont calculé la courbe des sourcils. Au moyen de l'analyse de groupe, ils ont comparé la hauteur et la courbe moyennes en se servant du test de Mann-Whitney. Ils ont utilisé l'analyse de régression pour déterminer le lien entre la courbe et l'âge. RÉSULTATS: La courbe moyenne diminuait considérablement entre 20 à 29 ans et 40 à 49 ans (0,22 par rapport à 0,12; P=0,03), puis augmentait entre 40 et 49 ans et 60 ans et plus (0,12 par rapport à 0,21;P=0,05). La hauteur médiane ne changeait pas de manière significative, tandis que l'apex de l'arche diminuait de manière significative entre 20 à 29 ans et 40 à 49 ans. L'analyse de régression a révélé un lien quadratique entre l'âge et la courbe, la diminution de la courbe jusqu'à la cinquième décennie étant directement proportionnelle à l'avancement en âge. Par la suite, l'âge n'était plus un élément significatif des changements de courbe. CONCLUSIONS: Avec l'âge, la courbe du sourcil diminue jusqu'à la cinquième décennie. L'âge ne joue plus un rôle important par la suite. Il faut donc choisir attentivement la technique de redrapage du front.