Evaluating the feasibility of a novel Marking Breast Oncoplastic Surgery Simulator (MBOSS) as a training tool for marking: a randomised trial.

BACKGROUND: Currently, volunteers and/or anatomical models are used for teaching oncoplastic surgery marking. However, as the breast is an intimate organ, recruiting volunteers is difficult, and the available droopy breast models have limitations. We evaluated the feasibility of a novel Marking Breast Oncoplastic Surgery Simulator (MBOSS) for the teaching of marking. METHODS: Breast/plastic surgeons/trainees, grouped according to their oncoplastic experience, were randomized to MBOSS or volunteer. All had a pre-test evaluation prior to receiving hands-on training in inverted T mammoplasty marking in their randomized group, followed by an assessment of their marking skills, by an examiner blinded to their group assignment. All participants then underwent post-test and course evaluations, and those who used MBOSS for training, also evaluated MBOSS realism. Learning outcomes between the two groups were compared using the Kirkpatrick educational model. RESULTS: Forty participants were enrolled. Demographics, baseline oncoplastic experience and pre-test results were comparable between the MBOSS and volunteer groups. For Kirkpatrick level 1 satisfaction outcomes, the two groups did not differ significantly. For level 2 knowledge assessment, MBOSS post-test scores were significantly higher (P=0.0471). For level 3 skill application and level 4 organizational impact evaluated 6 months post course, there were no significant differences between the groups. Although MBOSS may not mimic the breast completely, 95% of MBOSS-trained participants rated MBOSS as a good training tool and 85% would use MBOSS instead of a volunteer. CONCLUSIONS: MBOSS learning outcomes are comparable to outcomes using volunteers, making MBOSS an alternative for teaching oncoplastic surgery marking.

Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction And Radiotherapy (ABRAR study).

BACKGROUND: Timing of autologous breast reconstruction in patients requiring adjuvant radiotherapy remains contentious. The primary objective of this study was to assess clinical and patient reported outcomes in immediate reconstruction with radiotherapy compared to delayed reconstruction after radiotherapy, the two relevant clinical pathways for patients who need radiotherapy. METHODS: This retrospective UK multi-centre study grouped patients into three categories: immediate reconstruction with post-operative radiotherapy (IBR); delayed reconstruction after radiotherapy (DBR); control group of immediate reconstruction without radiotherapy (noRT). Data collection utilised clinician questionnaire, patient questionnaire (BreastQ) and medical examination. Examination assessed fat necrosis, texture, symmetry and overall result. RESULTS: 412 patients were recruited (IBR 104; DBR 119; noRT 189) with median follow-up time of 57 months. Post-operative complications were higher in IBR & noRT (p <0.001). Total number of operations for completion of reconstruction was similar in all groups. Completion of reconstruction after mastectomy was three years longer in DBR versus IBR. BreastQ domain scores were lower in IBR versus DBR and noRT (p <0.01) but all scores were within acceptable range (satisfaction with outcome: IBR 71; DBR 85; noRT 81). Examination scores were similar for IBR and DBR but lower than noRT (p <0.01). Correlation between BreastQ and examination scores was poor. CONCLUSIONS: Acceptable results are observed with either IBR or DBR, with high rates of patient and clinician satisfaction, low rates of complications, and a similar number of operations to complete reconstruction in all groups suggesting all options should be considered for patients.

Comparing oncoplastic breast conserving surgery with mastectomy and immediate breast reconstruction: Case-matched patient reported outcomes.

BACKGROUND: Oncoplastic breast conserving surgery (OBCS) allows women who may otherwise have mastectomy and immediate reconstruction (MxIR) the choice to conserve their breast yet avoid deformity. We compared the outcome of these options. METHODS: Two cohorts meeting study criteria were identified from prospectively audited series of women undergoing OBCS or MxIR. After case matching for age, tumour size and date of surgery, stratification by breast size and controlling for radiotherapy; body image scale (BIS) scores of psychosocial function and patient reported outcome measures (PROMs) for breast appearance and return to function were analysed. RESULTS: A total of 567 women (286 treated by OBCS and 281 by MxIR) fulfilled inclusion criteria. Demographics were similar between the two unmatched cohorts, except for radiotherapy, age and tumour size (all p < 0.001). Overall, BIS score (p = 0.002), self-rated breast appearance, return to work and function (all p < 0.001) significantly favoured OBCS. Case-matched women with larger breasts treated by OBCS reported better BIS scores (mean 3.30 vs. 5.37, p = 0.011) and self-rated breast appearance score (p < 0.001) than MxIR, whereas no significant difference was observed for smaller breasts. BIS and appearance favoured OBCS, regardless of whether radiotherapy would have been avoided if treated by MxIR. CONCLUSION: OBCS offers suitable women the option to avoid MxIR while providing faster recovery. Better psychosocial and self-rated satisfaction with breast appearance is achieved for OBCS in all groups, regardless of the need for radiotherapy, apart from those women with smaller breasts for whom the results are comparable.

Oncoplastic Breast Surgery: What, When and for Whom?

Oncoplastic surgery is integral to all breast cancer surgeries. The use of an aesthetic approach to breast conservation or mastectomy greatly enhances the range of options that can be offered to women with breast cancer and facilitates better outomes from it. It should be the standard of care. However, a structured approach to selecting appropriate techniques is essential, and although many operative procedures are reported, this article sets out to describe a set of principles and an algorithm by which the what, when and for whom for oncoplastic surgery can be defined.

A case-controlled study of the oncologic safety of fat grafting.

BACKGROUND: Currently, there is no clinical evidence of oncologic risk associated with fat grafting, although its safety has been questioned. The authors investigated the risk of relapse associated with fat grafting in women with a history of breast cancer. METHODS: Of 328 women with previously treated malignant breast disease who underwent fat grafting at the Nottingham Breast Institute, complete data were available for 211 (invasive carcinoma, n = 184; ductal carcinoma in situ, n = 27). Mean follow-up was 88 months after primary cancer surgery and 32 months after fat grafting. Control subjects were matched 2:1 for date of primary cancer operation (within 2 years), age (within 5 years), type of surgery, tumor histology, estrogen receptor status, and disease-free status by time equivalent to that of fat grafting. Final endpoints were tumor recurrence and death. Outcome results were compared with a systematic review of all patients undergoing fat grafting with adequate follow-up reported in the literature. RESULTS: No significant excess oncologic events were observed in patients who had fat grafting compared to controls with regard to local (0.95 percent versus 1.90 percent; p = 0.33), regional (0.95 percent versus 0 percent; p = 0.16), and distant recurrences (3.32 percent versus 2.61 percent; p = 0.65). A systematic review identified case series with a total of 1573 women who had fat grafting after primary oncologic breast surgery. The locoregional relapse rate for these patients was 2.92 percent (0.95 percent per year). CONCLUSION: This study has found no evidence of increased oncologic risk associated with fat grafting in women previously treated for breast cancer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Lateral thoracic artery perforator (LTAP) flap in partial breast reconstruction.

BACKGROUND: Partial breast reconstruction using pedicled perforator flaps from the thoracodorsal (TDAP) and lateral intercostal arteries (LICAP) is well described. The article introduces the lateral thoracic artery perforator (LTAP) flap as an additional valuable option from the lateral chest wall and reports clinical experience and outcomes. METHODS: The anatomy of the LTAP flap is reviewed and the results of a consecutive series are reported. RESULTS: In a series of 75 consecutive cases of lateral chest wall perforator flaps used for reconstruction of partial breast defects, 12 (17%) were raised as pure LTAP flaps, and a further 19 (27%) as combined LTAP/LICAP flaps. The LTAP was therefore used in 44% of flaps overall. One LTAP flap (delayed case) had early venous compromise that settled spontaneously. DISCUSSION: The LTAP flap is a reliable option for partial breast reconstruction from the lateral chest wall, particularly in the immediate setting. It allows comparable flap size to be harvested compared to LICAP flaps. The LTAP flap can be raised on its own pedicle allowing greater mobilization or it can be incorporated into the more commonly used LICAP flap to augment perfusion.

Effect of obesity on outcomes of free autologous breast reconstruction: a meta-analysis.

BACKGROUND: The prevalence of obesity is rising in Western society. The aim of this meta-analysis was to evaluate the available evidence regarding the effect of obesity on outcomes of free autologous breast reconstruction. METHODS: Pubmed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov were searched. Obesity was defined as a BMI ≥ 30. Comparable data from observational studies was combined for pooled analysis and quality assessment of observational studies was performed. RESULTS: Fourteen studies met the inclusion criteria (n = 6,043 patients). Pooled data analysis demonstrated significantly higher prevalences of overall complications, recipient site complications overall, donor site complications overall, donors site wound infection, donor site seroma, abdominal bulge/hernia, mastectomy skin flap necrosis, recipient site delayed wound healing, and partial flap failure, in obese (BMI ≥ 30) compared with nonobese (BMI < 30) patients. A BMI of 40 was identified as a threshold at which the prevalence of complications became prohibitively high. No randomized-controlled trials were found and all studies had methodological weaknesses. CONCLUSIONS: Complications in obese patients following free autologous breast reconstruction were higher than in their nonobese counterparts; however the majority of these complications were reported in the studies as being minor. Until better evidence is available this information will help when counseling patients.

Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature.

BACKGROUND: There remains controversy as to whether immediate autologous breast reconstruction with postoperative radiotherapy is associated with acceptable complications and aesthetic outcomes. This systematic review analyses the literature regarding outcomes of immediate autologous breast reconstruction with postoperative radiotherapy compared with no radiotherapy, as well as with delayed autologous breast reconstruction following post-mastectomy irradiation. METHODS: Pubmed (1966 to October 2012), Ovid MEDLINE (1966 to October 2012), EMBASE (1980 to October 2012), and the Cochrane Database of Systematic Reviews (Issue 10, 2012) were searched. Overall complications (including fat necrosis), fat necrosis, revisional surgery, loss of volume, and aesthetic outcome, were analysed individually. Comparable data from observational studies were combined for meta-analysis where possible and quality assessment of the studies was performed. RESULTS: The majority of studies of immediate autologous breast reconstruction and postoperative radiotherapy reported satisfactory outcomes (19 of 25 studies; n=1,247 patients). Meta-analysis of observational studies demonstrated no significant differences in total prevalence of complications (p=0.59) or revisional surgery (p=0.38) and a summary measure for fat necrosis favouring the group without radiotherapy (OR 2.82, 95% CI 1.35-5.92, p=0.006). The majority of studies comparing immediate reconstruction and postoperative radiotherapy with delayed reconstruction following post-mastectomy radiotherapy (10 of 12 observational studies; n=1,633 patients) reported satisfactory outcomes following immediate reconstruction. Meta-analysis of observational studies demonstrated no significant difference in overall incidence of complications (p=0.53) and fat necrosis (OR 0.63, 95% CI 0.29-1.38, p=0.25), and a summary measure for revisional surgery (OR 0.15, 95% CI 0.05-0.48, p=0.001) favouring the delayed surgery group. No randomised-controlled trials met the inclusion criteria, and all of the observational studies included were missing more than one important component for reporting of observational studies. DISCUSSION: The majority of studies reported satisfactory outcomes and a similar incidence of complications for immediate autologous breast reconstruction and adjuvant radiotherapy when compared with no radiotherapy or delayed reconstruction following radiotherapy; the proportion that required revisional surgery was higher though for immediate than delayed breast reconstruction. The findings are limited by the paucity of high quality data in the published literature, and until better data is available the findings of this review suggest that immediate autologous breast reconstruction should at least be considered when adjuvant chest wall radiotherapy is anticipated.

Contrast-enhanced magnetic resonance angiography for preoperative imaging in DIEP flap breast reconstruction.

BACKGROUND: Contrast-enhanced magnetic resonance angiography has been shown to be very accurate for identifying the perforator size, location, and intramuscular course, and the associated venous system, without exposing the patient to ionizing radiation. This study reports the authors' experience using this imaging modality in a large patient series. METHODS: A retrospective review of patients who had undergone preoperative contrast-enhanced magnetic resonance angiography followed by free abdominal flap breast reconstruction was conducted. The results of imaging were compared with intraoperative findings, and surgical outcomes were compared with scan data. The results were compared with control data in patients who did not undergo presurgical imaging. RESULTS: One hundred thirty-two patients underwent contrast-enhanced magnetic resonance angiography presurgical imaging, and the results were compared with 84 controls. The imaging was found to be accurate for evaluating the perforator anatomy for free abdominal flap planning, with a high concordance between imaging and intraoperative findings. Without presurgical angiography, the ratio of deep inferior epigastric perforator (DIEP) flap-to-free transverse rectus abdominis musculocutaneous flap harvest was 0.9:1; with presurgical imaging, the ratio was 1.6:1 (p < 0.05). With presurgical angiography, there was a mean reduction in operating time of 26 minutes for unilateral DIEP flap harvest and 40 minutes for bilateral harvest, although these values were not significant. There was a significant reduction in the partial flap failure rate with preoperative imaging. CONCLUSIONS: Presurgical imaging using contrast-enhanced magnetic resonance angiography demonstrates a high concordance with intraoperative findings. In this series, the percentage of flaps that were raised as DIEP flaps was significantly increased in patients who underwent preoperative imaging, and the partial flap failure rate was significantly reduced. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.(Figure is included in full-text article.).

Contrast-enhanced magnetic resonance angiography for preoperative imaging of deep inferior epigastric artery perforator flaps: advantages and disadvantages compared with computed tomography angiography: a United Kingdom perspective.

The anatomy of the anterior abdominal wall is highly variable and leads to uncertainty when harvesting a deep inferior epigastric artery perforator flap. Presurgical imaging has been shown to reduce the operating time, as well as reduce the rates of flap and donor site complications. The importance of imaging of the venous system has also been recognized for reducing the risk of venous congestion. The modalities currently available for presurgical imaging include handheld Doppler ultrasound, duplex ultrasound, computed tomographic angiography (CTA), and contrast-enhanced magnetic resonance angiography (CE-MRA). Of these, the most promising are CTA and CE-MRA, and advantages and disadvantages exist for both modalities. In this article, we review the use of CE-MRA for preoperative flap imaging and report our experience with its use in deep inferior epigastric artery perforator flap harvest, as well as compare it with CTA. We also explore the future directions for presurgical flap imaging.

Relationship between venous congestion and intraflap venous anatomy in DIEP flaps using contrast-enhanced magnetic resonance angiography.

BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flap harvest is associated with a significant rate of venous congestion; however, the reason for this has not yet been fully explained. Contrast-enhanced magnetic resonance angiography enables detailed evaluation of both the arterial and venous anatomies. METHODS: A retrospective review of DIEP flaps that underwent preoperative contrast-enhanced magnetic resonance angiography was performed. Outcomes were compared with preoperative radiologic reporting of contrast-enhanced magnetic resonance angiographic imaging, and anatomical data from the scans were also analyzed. RESULTS: Review of 54 DIEP flaps with venous system reporting was performed. Seven DIEP flaps suffered venous congestion, all of which were raised on perforators without direct connections between the venae comitantes and the main arborization of the superficial inferior epigastric vein. In the 47 DIEP flaps without venous congestion, 46 were raised on at least one perforator with a direct venous connection between the perforator venae comitantes and the main arborizations of the superficial inferior epigastric vein. There was an extremely significant association between the absence of a direct connection with the perforator venae comitantes on magnetic resonance angiography and the occurrence of venous congestion (p < 0.0001). Sixty-eight percent of all perforators had direct venous connections, which were significantly more likely to be located in the medial row. CONCLUSIONS: DIEP flaps elevated on perforators with venae comitantes with direct venous connections to the main arborization of the superficial inferior epigastric vein are significantly associated with a very low incidence of flap venous congestion. Contrast-enhanced magnetic resonance angiography allows detailed appraisal of the venous anatomy, which may minimize the risk of DIEP flap venous insufficiency and the need for salvage procedures.

Superior and superomedial pedicle wise-pattern reduction mammaplasty: maximizing cosmesis and minimizing complications.

Our center has refined a wise-pattern superior and superomedial pedicle breast reduction technique with predictable quality outcomes giving high patient satisfaction and a very low complication or revision rate. Fifty patients who underwent bilateral superior or superomedial pedicle wise-pattern breast reduction were included in the study. Demographic and perioperative data were collected, as were details of complications. A 21-item postal questionnaire was used to evaluate satisfaction with outcome parameters. The superomedial pedicle technique was used in 86% reductions, and the superior pedicle in 14%, and the mean weight removed from the breasts was 778 g (range, 244-1766 g). Mean patient satisfaction with outcome parameters, as well as maintenance of shape was excellent, as were mean improvements in symptoms of macromastia. No patient required a revision procedure. Superior and superomedial pedicle wise-pattern scar reduction mammaplasty with the technique presented predictably gives excellent results and patient satisfaction, with long-term preservation of shape.

A prospective assessment of shoulder morbidity and recovery time scales following latissimus dorsi breast reconstruction.

BACKGROUND: The impact on shoulder function from removal of the latissimus dorsi muscle in breast reconstruction is important because of the common nature of this operation. Informed consent requires us to discuss the impact of surgery and likely recovery times. The literature already supports the absence of long-term effects from this procedure. However, all studies and subsequent reviews are based on retrospective studies, thus making it impossible to assess recovery time scales compared with preoperative values. In this prospective study, the authors set out to define the impact on shoulder function and, importantly, to assess recovery time scales compared with preoperative values. METHODS: Shoulder range of motion, strength, function, and pain were assessed prospectively in 22 subjects who had latissimus dorsi muscle flap breast reconstruction. Assessments were carried out preoperatively and then at 6 weeks, 6 months, and 1 year postoperatively using standardized objective assessments. RESULTS: The results demonstrate no significant loss of range of motion, strength, function, or pain at 1 year. However, strength, disability scores, neural glide, and discomfort were still abnormal at 6 months and then normalized at 1 year. It was noted that the extended latissimus dorsi flap tended to have poorer scores and recovery compared with a latissimus dorsi flap and implant. CONCLUSION: The authors believe this information to be important to the patient, therapist, and surgeon in the assessment of postoperative recovery from this procedure.

Management of large volume CT contrast medium extravasation injury: technical refinement and literature review.

The incidence of radiographic contrast medium extravasation is on the rise due to the rapid increase in availability of contrast enhanced imaging. There is no consensus, however, regarding its management. There is a wide spectrum of clinical presentations, ranging from localised erythema and oedema to skin necrosis, which is related to the osmolarity and volume of the extravasated contrast medium. It is not possible to predict the degree of final tissue injury at initial examination. The increase in use of automated bolus injection has led to an increase in incidence of large volume extravasation injuries. Here we present a review of the literature regarding clinical presentation, risk factors, and management of contrast extravasation injuries. We also report the management of a large volume computed tomography contrast extravasation injury following mechanical bolus injection using a combination of liposuction and saline washout as described by Gault, and the use of compression by a Rhys-Davies exsanguinator as a technical refinement to achieve immediate resolution of the soft tissue oedema.