Comparing post-surgical outcomes of pre-pectoral versus dual-plane direct-to-implant breast reconstruction without increasing the use of acellular dermal matrix.

BACKGROUND: Direct-to-implant (DTI) reconstruction when performed using the dual-plane technique can be associated with increased postoperative pain, longer recovery, functional impairment, and animation deformity. These issues can be avoided by using the pre-pectoral technique that traditionally uses larger pieces of the acellular dermal matrix (ADM) and results in increased costs. It is unclear how these two methods compare when the technique is modified to avoid the use of additional ADM. METHODS: A retrospective chart review was conducted of all patients who underwent DTI breast reconstruction using a dual-plane or pre-pectoral technique between January 2014 and December 2019. Pre-pectoral breast reconstruction was performed using a partial anterior coverage technique, and therefore no additional ADM was used per case as compared to the dual-plane technique. Rates of post-surgical complications were compared between the two groups. RESULTS: Of 77 patients, 48 (86 breasts) underwent dual-plane reconstruction, whereas 29 (48 breasts) underwent pre-pectoral reconstruction. Mean follow-up time for the dual-plane and pre-pectoral groups was 23.3 and 8.7 months, respectively (p<0.001). There were no significant differences in the rates of any of the short-term post-surgical outcomes between the two groups: seroma (14% vs 6.3%, p = 0.175); hematoma (2.3% vs 4.2%, p = 0.617); skin/nipple necrosis (7% vs 10.4%, p = 0.522); wound skin infection (2.3% vs 2.1%, p = 1.0); wound dehiscence (4.7% vs 2.1, p = 0.654); and implant loss (1.2% vs 8.3%, p = 0.055). CONCLUSIONS: Pre-pectoral reconstruction using a partial anterior coverage technique appears to be a safe alternative to dual-plane reconstruction when considering short-term post-surgical complications.

Can We Reach a Consensus on the Appropriate Use of Before and After Photos in Breast Surgery?

Breast surgery is an area of practice where patients value before and after photographs (BAPs). Consensus is needed to develop guidelines to address the deficit in the literature regarding appropriate use of BAPs, as these may ultimately play a significant role in the breast surgery consent process. METHODS: Expert breast reconstructive surgeons participated in a modified nominal group technique (NGT) to establish expert consensus on categories and criteria to be used when evaluating appropriate use of BAPs as part of informed consent. Endorsement rate of 75% and coefficients of variance within and between rounds were conducted to determine validity of each criteria item's rank order. RESULTS: Eight experts participated in the NGT in-person meeting and subsequent online survey. five of seven categories were endorsed for discussion: purpose, image type, anatomy, results, and photographic integrity. Overall consensus was obtained for six of 11 criteria. Criteria items found to have consensus were: patients considering surgery being the intended photograph audience (100% endorsement, CV1 - CV2 = 0.01), use of photographic images (75% endorsement, CV1 - CV2 = 0.04), defining the standard clinical photograph by having patients in the same body position (100% endorsement, CV1 - CV2 = 0.14), anonymizing images by removing all digital tags (88% endorsement, CV1 - CV2 = 0.03) and patient identifiers (75% endorsement, CV1 - CV2 = 0.00), not limiting the number of photograph sets needed for sufficient representation (100% endorsement, CV1 - CV2 = 0.07), and representing average outcomes (100%, CV1 - CV2 = 0.06). CONCLUSIONS: Early use of this validated and effective technique helps identify potential consensus categories and criteria that surgeons recommend for the use of BAPs in the informed consent process. Further study is required.

Breast reconstruction: Updated overview for primary care physicians.

OBJECTIVE: To offer primary care providers a comprehensive summary of breast reconstruction options and complications. QUALITY OF EVIDENCE: A literature search was conducted in PubMed with no time restriction using the search terms breast reconstruction, summary, review, complications, and options. Levels of evidence range from I to III. MAIN MESSAGE: As breast cancer survival rates increase, the focus of breast cancer management must shift to include the restoration of a patient's quality of life after cancer. Breast reconstruction plays a crucial role in the restoration of normality for these women. Women who undergo mastectomy often suffer from challenges related to body image, self-esteem, and a decrease in quality of life scores. Cancer Care Ontario's Breast Cancer Treatment Pathway Map mandates that all women diagnosed with breast cancer who might require mastectomy be referred to a plastic surgeon to discuss reconstructive options before surgery. CONCLUSION: The knowledge and guidance of primary care providers is critical to effectively guiding and supporting patients who might undergo breast reconstruction in their decision-making processes. A thorough understanding of patient selection factors, modern options for breast reconstruction, and expected outcomes is essential.

Reconstruction mammaire: Aperçu actualisé à l'intention des médecins de soins primaires.

OBJECTIF: Présenter aux prestataires de soins primaires un résumé complet des options en matière de reconstruction mammaire et de leurs complications. SOURCES DE L'INFORMATION: Une recherche documentaire a été effectuée dans PubMed, sans restrictions relatives à la date de publication, à l'aide des expressions de recherche en anglais breast reconstruction, summary, review, complications et options. Les niveaux des données probantes varient de I à III. MESSAGE PRINCIPAL: Étant donné la hausse des taux de survie au cancer du sein, la prise en charge doit changer de cap pour inclure aussi la restauration de la qualité de vie de la patiente après le cancer. La reconstruction mammaire joue un rôle majeur pour un retour à la normale chez ces femmes. Les femmes qui subissent une mastectomie éprouvent souvent des difficultés quant à leur image corporelle et à leur estime de soi, et elles évaluent leur qualité de vie à la baisse. La carte des voies pathologiques d'Action Cancer Ontario préconise que toutes les femmes ayant reçu un diagnostic de cancer du sein qui pourraient avoir besoin d'une mastectomie soient envoyées en consultation en chirurgie plastique pour discuter des options de reconstruction avant l'opération. CONCLUSION: Les connaissances et les conseils des médecins de soins primaires sont essentiels pour bien orienter et appuyer les patientes dans leur processus décisionnel quant à la reconstruction mammaire. Il est nécessaire de bien comprendre les facteurs de sélection des patientes, les options contemporaines de reconstruction mammaire et les résultats attendus.

Patient-Reported Outcomes following Breast Conservation Therapy and Barriers to Referral for Partial Breast Reconstruction.

BACKGROUND: The purpose of this study was to evaluate the self-reported aesthetic outcome of breast conservation therapy in a generalized sample of patients, and to describe potential barriers to referral for partial breast reconstruction. METHODS: Consecutive breast conservation therapy patients completing radiotherapy over a 1-year period at a regional cancer center were identified. Eligible patients were contacted by means of mail/e-mail and invited to participate. Participants completed the BREAST-Q breast conservation therapy module along with a questionnaire examining feelings about breast reconstruction. Multiple regression analysis was performed using the satisfaction with breasts scale as the dependent variable. RESULTS: Surveys were completed by 185 of 592 eligible participants (response rate, 31.3 percent; mean age, 61 years) an average of 38 months after lumpectomy. The mean score for the BREAST-Q satisfaction with breasts scale was 59 of 100. Younger age (p = 0.038), lumpectomy reexcision (p = 0.018), and lumpectomy at a nonacademic center (p = 0.026) were significantly associated with lower satisfaction. Bra size, months from lumpectomy, and tumor quadrant/size were not significantly associated with satisfaction (p > 0.05). The most common statements regarding reconstruction were "I don't feel the need for it" (60.0 percent), "I don't like the thought of having breast implants" (22.7 percent), and "I don't want any more surgeon/doctor visits" (22.2 percent). Before lumpectomy, only 1.6 percent had a consultation for reconstruction, and only 22.7 percent were aware of this option. If offered, 33.1 percent of patients would have attended this consultation. CONCLUSION: There is an unmet demand for partial breast reconstruction, with an opportunity to advocate and increase awareness on behalf of patients undergoing breast conservation therapy.

Secondary Breast Augmentation.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Assess common clinical problems in the secondary breast augmentation patient. 2. Describe a treatment plan to correct the most common complications of breast augmentation. 3. Provide surgical and nonsurgical options for managing complications of breast augmentation. 4. Decrease the incidence of future complications through accurate assessment, preoperative planning, and precise surgical technique. SUMMARY: Breast augmentation has been increasing steadily in popularity over the past three decades. Many of these patients present with secondary problems or complications following their primary breast augmentation. Two of the most common complications are capsular contracture and implant malposition. Familiarity and comfort with the assessment and management of these complications is necessary for all plastic surgeons. An up-to-date understanding of current devices and techniques may decrease the need to manage future complications from the current cohort of breast augmentation patients.

Conservative mastectomies and immediate reconstruction with the use of ADMs.

BACKGROUND: In recent years, a novel approach to immediate breast reconstruction has been introduced with the advent of acellular dermal matrix (ADM). In the setting of conservative mastectomies where the native skin envelope is preserved, placement of ADM at the lower pole in continuity with the pectoralis major muscle (PMM) provides additional support, allowing direct-to-implant breast reconstruction. The following manuscript presents the senior author's experience with ADM-assisted reconstruction and provides a detailed description of surgical technique along with a comprehensive discussion of patient selection and potential complications. METHODS: A retrospective chart review of patients undergoing direct-to-implant breast reconstruction following skin sparing or nipple sparing mastectomy with the use of ADM (AlloDerm; LifeCell Corp., Branchburg, USA) was conducted at Women's College Hospital in Toronto over a 5-year period [2008-2013]. Demographic data, previous radiation therapy and post-operative complications were recorded. RESULTS: A total of 72 patients representing 119 breasts were identified. Average follow-up was 16 months (range, 3-51 months). Twenty-seven complications were recorded for a complication rate of 22.7% (27/119). Complications included six cases of capsular contracture (Baker III/IV), five cases of red skin syndrome, four cases of rippling, three cases of dehiscence and two cases of seroma. Overall, direct-to-implant reconstruction was successfully completed in 97.5% of breasts (116/119). One case of infection was treated with explantation and conversion to autogenous reconstruction. Two breasts with tissue necrosis or dehiscence had the implants removed and replaced with tissue expanders. Overall reoperation rate was 9.7% (7/72 patients). CONCLUSIONS: ADM assisted direct-to-implant breast reconstruction has been shown to be a safe option for women who are candidates for skin sparing or nipple sparing mastectomies. Judicious patient selection, effective collaboration between the oncologic and reconstructive surgeon, careful evaluation of post-mastectomy skin flaps and precise surgical technique are paramount to the success of this technique.

Surgical Strategies in the Correction of the Tuberous Breast.

Management of the tuberous breast represents one of the greatest surgical challenges in aesthetic breast surgery, requiring careful assessment and a methodical approach to obtain an acceptable result. The surgeon must be familiar with multiple techniques that can be performed individually or may be combined to address various aspects of the tuberous deformity. This article describes the etiology, anatomic features, identification, and classification of the tuberous breast, focusing on surgical management and potential pitfalls. Through case study, expected outcomes in the management of this complex problem are described.

Venous thromboembolism in abdominoplasty: a comprehensive approach to lower procedural risk.

BACKGROUND: Venous thromboembolism (VTE) is a serious and potentially life-threatening surgical complication. However, there is little consensus regarding appropriate VTE prophylaxis for plastic surgery patients. Risk factors as they apply to plastic surgery patients are unclear, and recent recommendations for chemoprophylaxis in these patients may expose them to other additional risks. OBJECTIVES: The authors examine perioperative and intraoperative measures, specifically those that have enabled a large number of patients to undergo outpatient abdominoplasty safely, with a reduced risk of VTE. METHODS: A retrospective review was performed of 404 consecutive abdominoplasty patients who were treated at a single outpatient surgery center between 2000 and 2010. Graded compression stockings and intermittent pneumatic compression devices were placed on all patients, and perioperative and intraoperative warming was strictly applied. Progressive tension suturing technique was performed in all cases and drains were eliminated. All patients received pain pumps, ambulated within one hour of surgery, and were discharged home the same day. Patient VTE risk factors were scored with the Caprini/Davison risk assessment model (RAM). Perioperative and intraoperative measures were taken to reduce factors that may increase VTE risk in abdominoplasty. Complications were recorded, including VTE events, seromas, hematomas, and infections. RESULTS: In this series, 247 abdominoplasty procedures were performed alone and 157 were combined with additional procedures. Under the RAM, 297 patients were considered "high risk" and 17 "highest risk." Abdominoplasty operative time was 100 ± 29 minutes. Only one case of deep vein thrombosis (DVT) occurred, in the calf. CONCLUSIONS: A comprehensive approach to perioperative and intraoperative patient care has allowed outpatient abdominoplasty to be safely performed without VTE chemoprophylaxis in patients with fewer than six risk factors.

Efficient breathing circuit for use at altitude.

We describe a case report of a subject suffering high-altitude cerebral and pulmonary edema successfully treated with low flow rates of supplemental oxygen administered with a breathing system designed to conserve oxygen supplies at high altitude.

Changes in respiratory control after 5 days at altitude.

These experiments examined changes in the chemoreflex control of breathing and acid-base balance after 5 days at altitude (3480 m) in six healthy males. The partial pressures of carbon dioxide (P(CO2)) at which ventilation increased during isoxic hypoxic and hyperoxic modified rebreathing tests at sea level fell significantly at altitude by mean+/-S.E.M. of 12.8+/-2.51 mmHg and 9.5+/-1.77 mmHg, respectively, but response slopes above threshold were unchanged. Altitude exposure produced a respiratory alkalosis evidenced by a decrease in mean resting end-tidal P(CO2) from 41+/-0.84 mmHg at sea level to 32+/-2.04 mmHg at altitude, but pH did not increase significantly from its sea level value. Blood samples were analyzed to discover acid-base changes, using a modification of the equations for acid-base balance proposed by [Stewart, P.A., 1983. Modern quantitative acid-base chemistry. Can. J. Physiol. Pharmacol. 61, 1444-1461]. While strong ion difference at altitude was not significantly different from its sea level value, albumin concentration was increased significantly from 38.6+/-0.30 g L(-1) to 49.8+/-0.76 g L(-1). We suggest that the respiratory alkalosis was produced by a fall in the chemoreflex threshold and pH was corrected by an elevation in the concentration of weakly dissociated protein anions.

The effects of carbon monoxide on respiratory chemoreflexes in humans.

As protection against low-oxygen and high-carbon-dioxide environments, the respiratory chemoreceptors reflexly increase breathing. Since CO is also frequently present in such environments, it is important to know whether CO affects the respiratory chemoreflexes responsiveness. Although the peripheral chemoreceptors fail to detect hypoxia produced by CO poisoning, whether CO affects the respiratory chemoreflex responsiveness to carbon dioxide is unknown. The responsiveness of 10 healthy male volunteers were assessed before and after inhalation of approximately 1200 ppm CO in air using two iso-oxic rebreathing tests; hypoxic, to emphasize the peripheral chemoreflex, and hyperoxic, to emphasize the central chemoreflex. Although mean (SEM) COHb values of 10.2 (0.2)% were achieved, no statistically significant effects of CO were observed. The average differences between pre- and post-CO values for ventilation response threshold and sensitivity were -0.5 (0.9) mmHg and 0.8 (0.3) L/min/mmHg, respectively, for hyperoxia, and 0.7 (1.1) mmHg and 1.2 (0.8) L/min/mmHg, respectively, for hypoxia. The 95% confidence intervals for the effect of CO were small. We conclude that environments with low levels of CO do not have a clinically significant effect acutely on either the central or the peripheral chemoreflex responsiveness to carbon dioxide.