Treating Pain and Fat Necrosis after Breast Cancer Surgery with Fat Grafting: Is one Session Enough?

BACKGROUND: Chronic pain after breast cancer surgery is affecting up to 60% of patients, causing significant morbidity to patients. Lately, fat grafting has been applied as a therapy for chronic neuropathic pain. METHODS: We report a series of eighteen patients, who were treated for pain after breast cancer surgery. Twelve patients had a breast conserving therapy, two a mastectomy and four an autologous flap-based reconstruction. While most presented with neuropathic pain, six patients had fat necrosis in their history. Most patients presented with severe pain (77%) and were treated with fat grafting sessions, performed by water-assisted liposuction. RESULTS: All patients responded to the interventions; the median number of fat grafting sessions was 2, the median duration of the interventions was 4 months, and the median follow-up period was 56.5 months. The median pain prior to the fat grafting procedure had an intensity of 8 (range 7-9) numeric rating scale points; after the first intervention, this was reduced to 4 (range 2.3-5.8); and after the second intervention, it was down to 2 (range 0.8-3.3). Patients with pain intensities of 4-5 had a good chance of achieving analgesia after one session. CONCLUSIONS: Fat grafting could be a new treatment modality for symptomatic fat necrosis: complete or partial suction of the necrosis and/or fat grafting around the necrosis to reduce inflammation and pain. Fat grafting proved a valuable tool, reducing pain or even achieving analgesia after breast cancer surgery presenting with a highly favorable risk-benefit ratio. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Decline in anti-Müllerian hormone concentrations following radioactive iodine treatment in women with differentiated thyroid cancer: A systematic review and meta-analysis.

AIM: Radioactive iodine (RAI) is frequently used as adjuvant therapy in patients with differentiated thyroid cancer (DTC). However, its effect on ovarian reserve has not been fully elucidated, with studies yielding inconsistent results. The aim of this study was to systematically review and meta-analyze the best available evidence regarding the effect of RAI on ovarian reserve in premenopausal women with DTC. METHODS: A comprehensive literature search was conducted in PubMed, Cochrane and Scopus, through to December 6th, 2020. Data were expressed as weighted mean difference (WMD) with a 95% confidence interval (CI). The I2 index was used to assess heterogeneity. RESULTS: Four prospective studies were included in the qualitative and quantitative analysis. Anti-Müllerian hormone (AMH) concentrations decreased at three (WMD -1.66 ng/ml, 95% CI -2.42 to -0.91, p<0.0001; I2 0%), six (WMD -1.58, 95% CI -2.63 to -0.52, p=0.003; I2 54.7%) and 12 months (WMD -1.62 ng/ml, 95% CI -2.02 to -1.22, p<0.0001; I2 15.5%) following a single RAI dose compared with baseline (three studies; n=104). With respect to follicle-stimulating hormone (FSH) concentrations, no difference was observed at six (WMD +3.29 IU/l, 95% CI -1.12 to 7.70, p=0.14; I2 96.8%) and 12 months (WMD +0.13 IU/l, 95% CI -1.06 to 1.32, p=0.83; I2 55.2%) post-RAI compared with baseline (two studies; n=83). No data were available for antral follicle count. CONCLUSIONS: AMH concentrations are decreased at three months and remain low at 6 and 12 months following RAI treatment in women with DTC. No difference in FSH concentrations post-RAI is observed.

Treating Anisomastia and Tuberous Breast with Fat Grafting: Technique and Evaluation of Outcomes Using BREAST-Q Surveys.

BACKGROUND: In the surgical correction of tuberous breast deformity, implants and regional flaps play a prominent role. Lately, fat grafting has been used as an alternative, but there is evidence that patient satisfaction is higher after correction with implants compared with lipofilling. METHODS: We report a tuberous breasts correction series of ten cases, enrolled between 2015 and 2018. Percutaneous fasciotomies and fat grafting were performed by the Body-Jet technique. Analysis of outcomes was undertaken with BREAST-Q surveys. RESULTS: The breast satisfaction scores increased from 0 to 75 (p < 0.01), the psychological well-being scores from 20 to 70 (p < 0.01) and the sexual well-being scores from 18.5 to 58 (p = 0.02), while the physical well-being scores remained stable (from 68 to 63, p = 0.2). The median outcome satisfaction score was 86. CONCLUSION: Scores of patient-reported outcomes after lipofilling can reach and even exceed those of patients corrected with implants, at the cost of more interventions. Fat grafting is beginning to establish itself as a true alternative in the treatment of tuberous breast deformity in patients with the appropriate fat deposits. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Fat Grafting and Auto-Augmentation Mastopexy After Breast Implant Removal: Technique and Evaluation of Outcomes Using BREAST-Q.

BACKGROUND: Auto-augmentation mastopexy after implant removal has been described as a possible alternative for women who do not opt for implant replacement and decline major reconstructive surgery. OBJECTIVES: This study aimed to evaluate patient satisfaction after auto-augmentation mastopexy relative to the final breast volume and to assess the role of fat grafting on patients' satisfaction and quality of life according to the BREAST-Q questionnaire. METHODS: Forty-seven breasts from 28 patients who underwent implant removal and auto-augmentation mastopexy were reviewed; 9 patients (group 1) were primarily treated with several fat grafting sessions with subsequent auto-augmentation, 5 (group 2) were treated primarily with auto-augmentation, but subsequently expressed a wish for breast augmentation by lipofilling, and 14 patients (group 3, control) had only auto-augmentation. RESULTS: Group 1 patients maintained their breast volume, and showed significant improvements in breast satisfaction, psychosocial well-being, and contentment with breast surgery outcomes (P = 0.01, ˂0.01, and ˂0.01, respectively). However, the physical well-being of this group, as well as response to final cup size or interaction parameters, did not improve (P = 0.06). In group 2, all except 1 patient had breast volume reduction to A cup, as was the case with one-third of the patients in control group 3 (group 3A, n = 5) who scored lower, and thus were less satisfied with the breast auto-augmentation than group 3B, who achieved final bigger cup sizes (P ˂ 0.01). CONCLUSIONS: Auto-augmentation mastopexy resulted in substantial improvements in the parameters measured by BREAST-Q. Thus, combined auto-augmentation mastopexy and lipofilling provided a better alternative treatment after breast implant removal.

Association between body mass index and oocyte maturation in patients triggered with GnRH agonist who are at high risk for severe ovarian hyperstimulation syndrome: an observational cohort study.

RESEARCH QUESTION: Is body-mass index (BMI) associated with oocyte maturation in women at high risk for developing severe ovarian hyperstimulation syndrome (OHSS) who are triggered with gonadotrophin releasing hormone (GnRH) agonist? DESIGN: Prospective observational cohort study. A total of 113 patients at high risk for severe OHSS (presence of at least 19 follicles ≥11 mm) pre-treated with gonadotrophin releasing hormone (GnRH) antagonists and recombinant FSH were administered 0.2 mg triptorelin to trigger final oocyte maturation. Patients were classified in two groups depending on their BMI: ΒΜΙ less than 25 kg/m2 (n = 72) and ΒΜΙ 25 kg/m2 or over (n = 41). Baseline, ovarian stimulation and embryological characteristics, as well as luteal-phase hormone profiles, were compared in patients classified into the two BMI groups. The main outcome measure was the number of mature oocytes. RESULTS: A significantly higher number of mature (metaphase II) oocytes (19 [18-21] versus 16 [13-20], P = 0.029) was present in women with BMI less than 25 kg/m2 compared with those with BMI 25 kg/m2 or greater. The number of retrieved oocytes, the number of fertilized oocytes, oocyte retrieval, maturation and fertilization rates were similar in the two groups. A significantly higher dose of recombinant FSH was required for patients with BMI 25 kg/m2 or greater compared with patients with BMI less than 25 kg/m2 (1875 [1650-2150] IU versus 1650 [1600-1750] IU, P = 0.003) and the two groups displayed different luteal phase hormonal profiles. CONCLUSIONS: Among women at high risk for developing severe OHSS who are triggered with a standard dose (0.2 mg) of the GnRH agonist triptorelin, women with BMI 25 kg/m2 or greater had significantly fewer mature oocytes, required a higher total dose of recombinant FSH compared with women with BMI less than 25 kg/m2.

Egg freezing and late motherhood.

Egg freezing was initially used as an intervention for iatrogenic ovarian insufficiency. Nowadays, it is not considered an experimental procedure, and it is increasingly popular among healthy women who wish to maintain their reproductive potential (fertility preservation). This review summarises the evidence on egg freezing technology, reproductive outcomes and long-term effects, as well as its psychological and socioeconomic implications. Egg freezing technology is advancing, with vitrification being the current method of choice, due to its effectiveness. The reproductive outcomes following egg freezing appear to be promising, though the strong negative association with maternal age has to be taken into consideration. Unfortunately, data on long-term outcomes are missing, raising safety issues. Egg freezing has several socioeconomic implications involving health risks, as well as financial and psychological factors.