Drain Removal Time in Pre-pectoral versus Dual Plane Prosthetic Breast Reconstruction following Nipple-sparing Mastectomy.

Pre-pectoral prosthetic breast reconstruction following nipple-sparing mastectomy (NSM) has become a popular approach compared with the dual plane technique. Our objective was to determine if there was a difference in time to postoperative breast drain removal in direct-to-implant or tissue expander reconstruction following NSM when comparing pre-pectoral with dual plane technique. Methods: A total of 200 patients (335 breasts) received NSM followed by implant or expander reconstruction at our institution between the years 2009 and 2020. Direct-to-implant reconstruction had 113 pre-pectoral versus 67 dual plane, and tissue expander reconstruction had six pre-pectoral versus 149 dual plane. Our analysis included age at mastectomy, body mass index, history of preoperative breast radiation, and smoking history. Case complications included seroma or hematoma, breast or axillary infection requiring antibiotics or operative washout, device replacement due to extrusion or infection, skin necrosis, and capsular contracture. Statistical analysis was completed with Pearson chi-square test, Fisher exact test, and the two-sample T-test using IBM SPSS Statistics 24.0 (IBM Corp., Armonk, N.Y.). Results: The average time until breast drain removal in dual plane implant patients was significantly less than in pre-pectoral implant patients (9.42 versus 14.01 days). The average time until breast drain removal in dual plane expander patients was significantly less than in pre-pectoral expander patients (11.47 versus 20.30 days). Conclusion: In both implant and expander reconstruction following NSM, patients receiving dual plane device placement had a shorter postoperative time until breast drain removal when compared with patients receiving pre-pectoral device placement.

The Impact Oncoplastic Reduction Has on Long-Term Recurrence in Breast Conservation Therapy.

BACKGROUND: The use of oncoplastic reduction techniques have many proven benefits over lumpectomy alone in the management of women with breast cancer. The impact it has on tumor recurrence is unclear. The purpose of this review was to evaluate the incidence of recurrence in patients who underwent oncoplastic reduction techniques compared to lumpectomy alone. METHODS: A prospectively maintained database of patients at Emory Hospital who underwent oncoplastic reduction techniques at the time of tumor resection was queried. These patients were compared to a series of patients who had lumpectomy alone over a similar period. For inclusion in the study, patients were at least 10 years since the time of the tumor resection. The main outcome of interest was tumor recurrence. RESULTS: There were 97 patients in the lumpectomy-only group and 95 patients in the oncoplastic reduction group, with an average follow-up of 7.8 years and 8.5 years, respectively. Patients in the oncoplastic group were younger (lumpectomy only, 61.4 years; oncoplastic reduction, 51.6 years; p < 0.001) and had larger tumors (lumpectomy only, 1.1 cm; oncoplastic reduction, 1.6 cm; p < 0.001). Local recurrence was 13 percent in the lumpectomy-only group and 9 percent in the oncoplastic reduction group (p = 0.34), and overall recurrence rates were similar (lumpectomy only, 15 percent; oncoplastic reduction, 24 percent; p = 0.13). Overall, surgical intervention (lumpectomy alone versus oncoplastic reduction) was not associated with local recurrence or any recurrence on univariate and multivariate analyses. CONCLUSION: Despite the oncoplastic reduction patients having a higher risk of recurrence and a more generous tumor resection, the long-term recurrence rates were equivalent when compared to breast-conserving therapy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preventing Infection in Implant-based Breast Reconstruction: Evaluating the Evidence for Common Practices and Standardized Protocols.

Infection following implant-based breast reconstruction (IBBR) results in increased rates of hospital readmission, reoperation, patient and hospital expenses, and reconstructive failure. IBBR is a complex, multistep procedure, and there is a relative lack of high-quality plastic surgery evidence regarding "best practices" in the prevention of implant infections. In the absence of strong data, standardizing procedures based on available evidence can reduce error and improve efficacy and outcomes. Methods: We performed a focused literature review of the available evidence supporting specific interventions for infection prevention in the preoperative, intraoperative, and postoperative phases of care that are applicable to IBBR. In addition, we examined previously published standardized perioperative protocols for implant reconstruction. Results: Preoperative, intraoperative, and postoperative planning and organization is crucial in IBBR. Preoperative planning involves skin decolonization in advance of surgery with either chlorhexidine gluconate or mupirocin. Intraoperative methods that have shown potential benefit include double-gloving, breast pocket irrigation, separate closing instruments, and the utilization of "no-touch" techniques. In the postoperative period, the duration of drain removal and postoperative antibiotic administration play an important role in the prevention of surgical site infection. Conclusions: There is a crucial need to establish an evidence-based set of "best practices" for IBBR, and there exists a paucity of evidence in the breast literature. These data can be utilized to develop a standardized protocol as part of a rigorous quality improvement methodology.

The Incidence of Occult Malignant and High-Risk Pathologic Findings in Breast Reduction Specimens.

BACKGROUND: The goal of this study was to determine the incidence of occult malignancy and high-risk breast pathologic findings in patients who undergo breast reduction procedures. METHODS: Medical records of consecutive patients who underwent reduction mammaplasty performed by the senior authors (A.L. and G.W.C.) at Emory University Hospital between 1997 and 2018 were reviewed. Data regarding patient demographics, personal or family history of malignancy, operative technique, pathologic findings, and follow-up were extracted. Patients were categorized into two groups, those with and those without breast cancer. Group A patients underwent reduction for symptomatic macromastia, and group B underwent contralateral reduction for unilateral breast cancer treated with oncoplastic partial or total breast cancer reconstruction. Pathologic findings were divided into four groups; normal, benign, high-risk, and malignant. RESULTS: A total 1014 patients (1419 breast reductions) were included in the study. Comparing groups A and B, mean age was 37.8 ± 16.2 years versus 54.5 ± 11.1 years (p < 0.001), mean body mass index was 34.1 ± 7.6 kg/m2 versus 33.3 ± 7.4 kg/m2 (p = 0.2), and average reduction weight was 875.6 ± 491 g versus 723.7 ± 438 g (p < 0.001). The incidence of high-risk or malignant lesions was 1.8 percent (n = 15) in group A and 8 percent (n = 49) in group B (p < 0.001). On multivariable logistic regression analysis, age and personal history of breast cancer were positive predictors for high-risk and malignant lesions. CONCLUSIONS: The incidence of abnormal pathologic findings in breast reduction specimens is not uncommon, and occult malignancy or high-risk lesions can be found, especially in patients with contralateral breast cancer. Appropriate specimen orientation, diligence with checking the pathologic findings, and open communication with the pathologist are crucial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Secondary Surgeries After Oncoplastic Reduction Mammoplasty.

PURPOSE: The oncoplastic reduction approach is a popular option for women with breast cancer and macromastia. Although the benefits of this approach are numerous, data on the need for secondary surgeries are limited. We evaluated the need for all secondary surgeries after oncoplastic reduction in an attempt to understand the incidence and indications. METHODS: All patients with breast cancer who underwent an oncoplastic breast reduction at the time of the tumor resection were queried from a prospectively maintained database from 1998 to 2020 (n = 547) at a single institution. Secondary surgical procedures were defined as any unplanned return to the operating room. Demographic and clinical variables were analyzed, and secondary surgeries were classified and evaluated. The timing and rates of secondary surgery were evaluated and compared with clinical variables. RESULTS: There were 547 patients included in this series with a mean age of 55 years and body mass index of 33.5. Mean duration of follow-up was 3.8 years. One hundred and seventeen (21%) patients underwent 235 secondary surgeries, with an average of 1.4 operations until stable reconstruction was obtained. The reason for the secondary surgery was involved margins (7.5%), major complications (8.6%), aesthetic improvement (13.3%), and completion mastectomy (5.3%). Age 65 years and younger age was associated with any subsequent procedure (P = 0.023) and revision for cosmesis (P = 0.006). Patients with body mass index greater than 35 had increased secondary surgeries for operative complications (P = 0.026). CONCLUSIONS: Secondary surgeries after oncoplastic breast reduction procedures are common. Management of margins and complications, such as hematoma and infection, are early indications, with aesthetic improvement, wound healing complications, fat necrosis, and recurrence being late reasons. The most common reason for reoperation is aesthetic improvement, especially in younger patients. Attention to surgical technique and patient selection will help minimize secondary surgeries for the nononcological reasons.

A Systematic Review of Breast Irrigation in Implant-Based Breast Surgery.

BACKGROUND: Aesthetic and reconstructive implant-based breast surgeries are some of the most frequently performed procedures by plastic surgeons. As such, prevention of implant infection is of high importance. However, there remains no criterion-standard protocol for irrigation of the breast pocket. This review focuses on current irrigation practices in implant-based breast surgery. METHODS: Four databases were used to search for all studies, including randomized controlled trials, retrospective cohort, and prospective cohort, containing original data related to the outcomes investigated in this study. Search terms included "breast," "irrigation," and "infection" in different combinations to isolate studies that focused on irrigation methods in both reconstructive and augmentation surgeries. Our selection criteria specifically concentrated on those studies that explicitly related irrigation procedures to rates of clinical infection and/or capsular contracture. Each was compiled into a table in chronological order to make comparisons between the differing irrigation methods. RESULTS: Our search returned 239 full-text articles eligible for our review. Two independent screeners identified 9 studies that met the inclusion criteria. This included 1 prospective study and 8 retrospective studies. Two studies reported the use of chlorhexidine gluconate irrigation resulting in protection from clinical infection. Two studies investigated the role of triple antibiotic solution (TAS) either alone or combined with something else on risk of infection, and 3 reported TAS use on rates of capsular contracture. Two additional studies investigated the role of single antibiotic irrigation, concluding that some antibiotic regimen for irrigation may be sufficient in the breast pocket. Interestingly, one study noted the potential use of povidone-iodine (Betadine) as a method of irrigation. CONCLUSIONS: These data suggest that chlorhexidine gluconate, Betadine, and TAS irrigation of the breast pocket can provide protection against infection and implant loss in both reconstruction and augmentation surgeries.

The impact of axillary node surgery on outcomes following immediate breast reconstruction.

Immediate breast reconstruction (IBR) has become the most common method for postmastectomy reconstruction. Axillary lymph node dissection is performed for the staging of patients, but the impact of IBR with nodal surgery on postoperative complications remains elusive. The present study aims to investigate the impact of concomitant axillary lymph node surgery on postoperative complications. We conducted a retrospective study of patients who underwent IBR from 2000 to 2014. We recorded and analyzed patient data to determine the association between nodal surgery and postsurgical complications. Univariate and multivariate analyses were utilized to elucidate the risk of a complication given nodal surgery, sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND), and type of incision for nodal access. A total of 986 breast reconstructions were included for analysis. Overall incidence of postoperative complications per breast that received nodal surgery was 35.9% (n = 230/642), compared to 25.6% (n = 88/344) in breasts that did not have concomitant nodal surgery (P = .001). Nodal surgery was found to increase risk of all complications with an odds ratio of 1.62 (P = .001). Moreover, complications were significantly higher in patients whose nodes were accessed via mastectomy incision (39.4%) when compared to a separate incision (33.5%). Multivariate analysis showed that nodal sampling through the mastectomy incision is a significant risk factor for seroma, with an odds ratio of 3.60 (P = .002). We did not observe differences in breast complications in patients who underwent SLNB vs ALND. These factors should be taken into account in the approach to breast reconstruction during lymphadenectomy.

Surgical Outcomes in Prepectoral Breast Reconstruction.

BACKGROUND: Prepectoral breast reconstruction has reemerged as a popular option for prosthetic-based breast reconstruction. Recent published literature highlights good outcomes; however, techniques are evolving and options exist for different technologies. The aim of this study is to evaluate short-term complication rates of prepectoral reconstructions using Cortiva acellular dermal matrix. METHODS: A multicenter retrospective study was conducted of all patients who underwent mastectomy with immediate direct-to-implant or 2-stage prepectoral breast reconstruction with Cortiva (RTI Surgical, Alachua, Fla.) between January 2016 and September 2018. The incidence of surgical complications was determined and studied against patient demographics and procedural details. RESULTS: One-hundred eighteen patients met the inclusion criteria for a total of 183 individual breasts reconstructed with prepectoral implant. Average length of follow-up was 9.26 months (range, 1.0 month to 2.5 years). Thirty-two breasts (17.49%) experienced 1 or more complications. Prepectoral reconstruction was successful 89.07% of the time. Infection was the most common cause of both reoperation and implant failure, with 7.65% of all breasts requiring washout and 5.46% failing prosthetic reconstruction secondary to infection. CONCLUSIONS: Surgical outcomes for prepectoral breast reconstruction using 2-stage and direct-to-implant are similar and comparable to the literature for dual-plane reconstruction, with infection being the main cause of failure.

Survey Based Assessment of Burnout Rates Among US Plastic Surgery Residents.

PURPOSE: The purpose of this study was to analyze the rates of burnout and contributory factors among US plastic surgery residents. METHODS: The Maslach Burnout Inventory Human Services Survey was emailed to program coordinators of American College of Graduate Medical Education-accredited plastic surgery residencies. Scores are provided for 3 subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment. Normative scoring tables (low, average, high) were used for comparison. Residents were asked questions relating to their personal life (age, postgraduate year, marital status, and program characteristics). RESULTS: One hundred thirteen residents responded. The average age was 31.6 years (range, 25-43 years) and postgraduate year of 4.6 (range, 1-10). There were equal male and female respondents. Most were from integrated-only residencies (n = 59, 52.2%). On average, the majority reported working 50 to 80 hours per week (n = 93, 82.3%), spending the majority of time in tertiary referral centers (n = 107, 94.7%). Most received and took 3 weeks of vacation per year (n = 68, 60.7%). Furthermore, 65.5% met the definition of burnout by their scores from at least 1 subscale.The number of hours worked per week significantly correlated with increased scores in the EE and DP subscales. Residents who worked more than 80 hours per week had significantly higher scores in the EE and DP categories. Residents who had less than 2 weeks of vacation per year trended toward experiencing more EE (EE; 46.0, P = 0.077). The type of program (independent vs integrated), sex, having a significant other outside of the home, kids, and local family support did not significantly affect burnout scores for any subscales. CONCLUSIONS: Burnout exists among plastic surgery residents especially in the DP subscale. Working longer hours and less vacation correlates with increased rates of burnout among residents.

The Biosynthetic Option as an Alternative in Complex Abdominal Wall Reconstruction.

Synthetic mesh and acellular dermal matrix reinforcement during complex abdominal wall reconstruction (CAWR) have significantly improved outcomes. In an attempt to further improve outcomes, we combined both into a single biosynthetic by suturing a synthetic mesh on top of porcine acellular dermal matrix. Our aim was to review our experience with this new technique. Patients undergoing CAWR with the biosynthetic mesh were reviewed from a prospective database from 2015 to 2018. A total of 39 patients were 56.3 ± 10.9 years old, white (59.0%), and female (74.4%), with 31.9 ± 7.4 kg/m of body mass index. Eight repairs were performed on patients classified as greater than or equal to modified Ventral Hernia Working Group (mVHWG) class 3a, and 41.0% followed a concurrent resection of previously placed mesh. The biosynthetic mesh was placed as an underlay (51.3%) or inlay (46.2%) with primary closure in 51.3% and component separation in 12.8%. Recurrence at 3 years of follow-up occurred in 3 patients (7.7%). Complications within 60 days occurred in 6 patients (15.4%), including 4 soft tissue infections-one requiring explantation, with a total of 2 patients (5.1%) requiring explantation overall. Type 2 diabetes, previous mesh removal, component separation, and mVHWG class 3b independently predicted noninfectious complications. Male sex and mVHWG class 3b independently predicted surgical site infection. No predictors were found for recurrence. Biosynthetic mesh does not seem to increase the risk of early complications and may reduce recurrences and improve long-term outcomes after CAWR.

A Comparison of Acellular Dermal Matrices in Abdominal Wall Reconstruction.

BACKGROUND: There is a growing literature of evidence that the use of acellular dermal matrices (ADMs) in abdominal wall reconstruction (AWR) for high-risk patients provides superior complication profiles when compared with standard synthetic mesh. Here we compare Fortiva, Strattice, and Alloderm ADMs in AWR. METHODS: In a prospectively maintained database, all patients undergoing AWR between January 2003 and November 2016 were reviewed. Hernia recurrence and surgical site occurrence (SSO) were our primary and secondary endpoints. Kaplan-Meier survival curves and logistic regression models were used to evaluate risks for hernia recurrence and SSO. RESULTS: A total of 229 patients underwent AWR with 1 of 3 ADMs. Median follow-up time was 20.9 months (1-60 months). Cumulative recurrence rates for each mesh were 6.9%, 11.2%, and 22.0% (P = 0.04), for Fortiva, Strattice, and Alloderm groups. Surgical site occurrence for each mesh was 56.9%, 49.0%, and 49.2%, respectively. Seroma was significantly lower in the Fortiva group (1.4%; P = 0.02). Independent risk factors hernia recurrence included body mass index of 30 kg/m(2) or higher and hypertension. Adjusted risk factors included oncologic resection for hernia recurrence (odds ratio, 5.3; confidence interval, 1.1-97.7; P = 0.11) and a wound class of contaminated or dirty/infected for SSO (odds ratio, 3.6; confidence interval, 1.0-16.6; P = 0.07). CONCLUSIONS: Acellular dermal matrices provide a durable repair with low overall rate of recurrence and complications in AWR. The recurrence and complication profiles differ between brands. With proper patient selection and consideration, ADMs can be used confidently for a variety of indications and wound classifications.

The Impact of Mesh Reinforcement with Components Separation for Abdominal Wall Reconstruction.

The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

BACKGROUND: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery. METHODS: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded. RESULTS: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication. CONCLUSIONS: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery.

BACKGROUND: Autoaugmentation techniques have been applied to oncoplastic reductions to assist with filling larger, more remote defects, and to women with smaller breasts. The purpose of this report is to describe the use of autoaugmentation techniques in oncoplastic reduction and compare the results with those of traditional oncoplastic reduction. METHODS: The authors queried a prospectively maintained database of all women who underwent partial mastectomy and oncoplastic reduction between 1994 and October of 2015. The autoaugmentation techniques were defined as (1) extended primary nipple autoaugmentation pedicle, and (2) primary nipple pedicle and secondary autoaugmentation pedicle. Comparisons were made to a control oncoplastic group. RESULTS: There were a total of 333 patients, 222 patients (67.7 percent) without autoaugmentation and 111 patients (33 percent) with autoaugmentation (51 patients with an extended autoaugmentation pedicle, and 60 patients with a secondary autoaugmentation pedicle). Biopsy weight was smallest in the extended pedicle group (136 g) and largest in the regular oncoplastic group (235 g; p = 0.017). Superomedial was the most common extended pedicle, and lateral was the most common location. Inferolateral was the most common secondary pedicle for lateral and upper outer defects. There were no significant differences in the overall complication rate: 15.5 percent in the regular oncoplastic group, 19.6 percent in the extended pedicle group, and 20 percent in the secondary pedicle group. CONCLUSIONS: Autoaugmentation techniques have evolved to manage complex defects not amenable to standard oncoplastic reduction methods. They are often required for lateral defects, especially in smaller breasts. Autoaugmentation can be performed safely without an increased risk of complications, broadening the indications for breast conservation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy.

The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Neoadjuvant Therapy Combined With Oncoplastic Reduction for High-Stage Breast Cancer Patients.

OBJECTIVE: Oncoplastic surgery has been shown to be a good alternative to breast conservation surgery (BCS) alone for patients with breast cancer. Its role in patients with advanced disease is unclear. In this study, we evaluate the safety of oncoplastic BCS (OBCS) in patients who received neoadjuvant therapy (NT) for high stage breast cancer. METHODS: The oncologic outcomes of consecutive patients classified as high stage (>T2 or at least N1) who received NT followed by BCS at EUH by a single breast surgeon (T.M.S.) from September 2004 until June 2015 were compared with those who received BCS combined with an oncoplastic reduction. Patients were surveyed using the BREAST-Q to determine their satisfaction after surgery. RESULTS: A total of 87 patients were included in this series. The mean initial tumor size (4.37 vs 2.56 cm), the weight of the surgical specimen, and the post-NT tumor size were all larger in the OBCS group as compared with BCS alone (1.54 vs 1.29 cm). The mean follow-up was 44 months. The average percent reduction in tumor size in response to NT was slightly greater in the OBCS group (61 vs 52%). Oncologic outcomes were similar for OBCS reduction and BCS groups, respectively: positive margin rate, reexcision rate, completion mastectomy rate, local recurrence rate, and 5-year DSS. Patient satisfaction was similar between the 2 groups. CONCLUSIONS: The oncoplastic approach in high stage patients treated with neoadjuvant systemic Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation therapy appears to be as safe and effective when compared to BCS alone. Oncoplastic BCS paired with NT broadens the indication for BCS for patients with larger tumor size.

Oncoplastic Breast Reduction Technique and Outcomes: An Evolution over 20 Years.

BACKGROUND: Reduction mammaplasty at the time of lumpectomy is a good option in women with breast cancer and macromastia. We critically evaluated refinements and outcomes of this technique. METHODS: A prospectively maintained database was reviewed of all women with breast cancer who received lumpectomy and reduction mammaplasty at our institution from 1994 to 2015. Patients' demographics were reviewed. Preoperative and postoperative patient satisfaction (BREAST-Q) was determined. Comparisons were made between early and recent cases. RESULTS: There were 353 patients included. Average age was 54 (range, 21 to 80 years), with the largest number having stage I disease [n = 107 of 246 (43.5 percent)]. Average lumpectomy specimen was 207 g (range, 11.6 to 1954 g) and total reduction weight averaged 545 g (range, 21 to 4102 g). Tumor size averaged 2.02 cm (range, 0.00 to 15.60 cm). The positive margin rate was 6.2 percent (n = 22). Completion mastectomy rate was 9.9 percent (n = 35). Overall complication rate was 16 percent. The recurrence rate was 5.2 percent (n = 10 of 192) at a mean follow-up of 2 years (range, 2 months to 15 years). Resection weights greater than 1000 g were associated with having a positive margin (16.7 percent versus 5.0 percent; p = 0.016), and tended to be associated with having a completion mastectomy (p = 0.069). Positive margin and completion mastectomy rates have been lower in the past 10 years. Over 1 year postoperatively, women reported increased self-confidence (p = 0.020), feelings of attractiveness (p = 0.085), emotional health (p = 0.037), and satisfaction with sex life (p = 0.092). CONCLUSIONS: The oncoplastic reduction technique is effective and results in improved patient-reported outcomes. Resections over 1000 g are associated with a higher incidence of positive margins and may increase the risk for completion mastectomy. Outcomes have improved with experience and refinement in technique.

A Prospective Randomized Trial of the Efficacy of Fibrin Glue, Triamcinolone Acetonide, and Quilting Sutures in Seroma Prevention after Latissimus Dorsi Breast Reconstruction.

BACKGROUND: Donor-site seroma is the most common complication following latissimus dorsi flap breast reconstruction. Various agents and techniques have attempted to minimize seroma formation. The purpose of this study was to compare the efficacy of different products and quilting sutures at seroma prevention. METHODS: This is a single-center, double-blinded, randomized, controlled trial of a consecutive series of breast cancer patients (n = 96) undergoing latissimus dorsi flap reconstruction performed by a single surgeon. Patients were randomized to receive (1) fibrin glue (Tisseel) (n = 23), (2) triamcinolone acetonide (n = 26), or (3) normal saline (control) (n = 27) sprayed into the donor site. The fourth arm included donor-site quilting sutures (n = 20). Outcomes included seroma, drain output, and days to last drain removal. Drain removal was standardized at less than 30 cc/day. RESULTS: All groups were matched evenly without differences in risk, procedures, or complications. The overall seroma rate was 31.3 percent (n = 30). The quilting group had significantly less drainage for weeks 1 (p = 0.006) and 2 (p = 0.050) postoperatively. Quilting statistically reduced the incidence of seromas to 5.0 percent (n = 1; p = 0.038) compared with other groups (control, 34.5 percent; fibrin, 27.6 percent; and triamcinolone, 37.6 percent). Drains were removed 10 days earlier with quilting (control, 35.5 days; fibrin, 39.5 days; triamcinolone, 37.4 days; and quilting, 25.8 days; p = 0.001). The incidence of all other complications was similar between groups. CONCLUSION: The use of quilting donor sites significantly decreases the incidence of donor-site seromas and leads to earlier drain removal following latissimus dorsi flap reconstruction and maintains a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A Histological Comparison of Two Human Acellular Dermal Matrix Products in Prosthetic-Based Breast Reconstruction.

BACKGROUND: Acellular dermal matrices (ADMs) are an integral component of breast reconstruction. The ideal matrix would be relatively immuno-inert, allow rapid vascularization, and be affordable. The purpose of this study was to histologically compare 2 commonly used ADM products. METHODS: This is a prospective histological study of 17 patients (20 breasts) following prosthetic-based breast reconstruction with ADM: Alloderm (LifeCell Corp, Branchburg, N.J.) or Cortiva (RTI Surgical, Alachua Fla.). Biopsies were taken from the dermal matrix and natural capsules surrounding the expander/implant during secondary surgery [Range, 72-694 days (mean, 217 days)]. Biopsy specimens were prepared via hematoxylin and eosin, Masson's trichrome, elastin, and transforming growth factor (TGF)-1 stains. Quantitative analysis of staining was performed with ImageJ software. The clinical outcome of each patient is analyzed in relation to capsule architecture and ADM performance. RESULTS: There were 7 breasts in the Alloderm group and 13 in the Cortiva group. Both groups had similar demographic, aesthetic results, and complication profiles. The TGF-1 staining demonstrated significantly lower levels in the Cortiva capsules (P = 0.0139). The percentage of elastin and collagen are similar in the Cortiva, Alloderm, and natural peri-implant capsules. The native capsules show a significantly greater number of blood vessels when compared with Cortiva and Alloderm (P = 0.0371 and P = 0.0347, respectively); however, there is no difference in vascular pattern between the 2 dermal matrices. DISCUSSION: Postoperatively, Cortiva demonstrates equal vascularity with less TGF-1 activation compared with Alloderm. The clinical success and complication profile were similar between the Alloderm and Cortiva patients.