Skin-sparing mastectomy for the treatment of breast cancer.

BACKGROUND: Skin-sparing mastectomy (SSM) is a surgical technique that aims to maximize skin preservation, facilitate breast reconstruction, and improve cosmetic outcomes. Despite its use in clinical practice, the benefits and harms related to SSM are not well established. OBJECTIVES: To assess the effectiveness and safety of skin-sparing mastectomy for the treatment of breast cancer. SEARCH METHODS: We searched Cochrane Breast Cancer's Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 9 August 2019. SELECTION CRITERIA: Randomized controlled trials (RCTs), quasi-randomized or non-randomized studies (cohort and case-control) comparing SSM to conventional mastectomy for treating ductal carcinoma in situ (DCIS) or invasive breast cancer. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. The primary outcome was overall survival. Secondary outcomes were local recurrence free-survival, adverse events (including overall complications, breast reconstruction loss, skin necrosis, infection and hemorrhage), cosmetic results, and quality of life. We performed a descriptive analysis and meta-analysis of the data. MAIN RESULTS: We found no RCTs or quasi-RCTs. We included two prospective cohort studies and twelve retrospective cohort studies. These studies included 12,211 participants involving 12,283 surgeries (3183 SSM and 9100 conventional mastectomies). It was not possible to perform a meta-analysis for overall survival and local recurrence free-survival due to clinical heterogeneity across studies and a lack of data to calculate hazard ratios (HR).  Based on one study, the evidence suggests that SSM may not reduce overall survival for participants with DCIS tumors (HR 0.41, 95% CI 0.17 to 1.02; P = 0.06; 399 participants; very low-certainty evidence) or for participants with invasive carcinoma (HR 0.81, 95% CI 0.48 to 1.38; P = 0.44; 907 participants; very low-certainty evidence). For local recurrence-free survival, meta-analysis was not possible, due to high risk of bias in nine of the ten studies that measured this outcome. Informal visual examination of effect sizes from nine studies suggested the size of the HR may be similar between groups. Based on one study that adjusted for confounders, SSM may not reduce local recurrence-free survival (HR 0.82, 95% CI 0.47 to 1.42; P = 0.48; 5690 participants; very low-certainty evidence).  The effect of SSM on overall complications is unclear (RR 1.55, 95% CI 0.97 to 2.46; P = 0.07, I2 = 88%; 4 studies, 677 participants; very low-certainty evidence). Skin-sparing mastectomy may not reduce the risk of breast reconstruction loss (RR 1.79, 95% CI 0.31 to 10.35; P = 0.52; 3 studies, 475 participants; very low-certainty evidence), skin necrosis (RR 1.15, 95% CI 0.62 to 2.12; P = 0.22, I2 = 33%; 4 studies, 677 participants; very low-certainty evidence), local infection (RR 2.04, 95% CI 0.03 to 142.71; P = 0.74, I2 = 88%; 2 studies, 371 participants; very low-certainty evidence), nor hemorrhage (RR 1.23, 95% CI 0.47 to 3.27; P = 0.67, I2 = 0%; 4 studies, 677 participants; very low-certainty evidence). We downgraded the certainty of the evidence due to the risk of bias, imprecision, and inconsistency among the studies. There were no data available on the following outcomes: systemic surgical complications, local complications, explantation of implant/expander, hematoma, seroma, rehospitalization, skin necrosis with revisional surgery, and capsular contracture of the implant. It was not possible to perform a meta-analysis for cosmetic and quality of life outcomes due to a lack of data. One study performed an evaluation of aesthetic outcome after SSM: 77.7% of participants with immediate breast reconstruction had an overall aesthetic result of excellent or good versus 87% of participants with delayed breast reconstruction. AUTHORS' CONCLUSIONS: Based on very low-certainty evidence from observational studies, it was not possible to draw definitive conclusions on the effectiveness and safety of SSM for breast cancer treatment. The decision for this technique of breast surgery for treatment of DCIS or invasive breast cancer must be individualized and shared between the physician and the patient while considering the potential risks and benefits of available surgical options.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL.

BACKGROUND: Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL. OBJECTIVES: The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance. METHODS: A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement. RESULTS: The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria. CONCLUSIONS: BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

Serratus anterior muscle flap as a salvage procedure in exposed implant-based breast reconstruction.

BACKGROUND: Implant-based breast reconstruction (IBR) is the most common approach to reconstruct mastectomy deffects. Infection following breast reconstruction can be devastating and lead to loss of the reconstruction due to the need of implant removal. The serratus anterior muscle flap is widely used during breast reconstruction to provide coverage of the implant/expander. METHODS: We present the application of the serratus anterior muscle flap to treat implant exposure after breast reconstruction. CASES PRESENTATION: Two patients who experienced implant exposure after breast reconstruction were successfully treated with partial capsulectomy, pocket irrigation and implant coverage with a serratus anterior muscle flap. RESULTS: No post operative complications have been observed while implant retention was achieved in both cases. CONCLUSIONS: The serratus anterior muscle flap is an option to treat implant exposure following breast reconstruction in selected cases. This flap could be used to prevent implant exposure in critical cases.

Subfascial transaxillary breast augmentation without endoscopic assistance: technical aspects and outcome.

BACKGROUND: Although transaxillary breast augmentation (TBA) is a well-studied procedure, few previous reports exist concerning the subfascial technique, especially without endoscopic assistance. This study aimed to analyze the feasibility of the technique after breast augmentation in terms of its indication, surgical technique, limitations, and clinical outcome. METHODS: For this study, 42 patients underwent TBA without endoscopic assistance. The technique was indicated for patients with breasts of small or moderate volume without ptosis, patients who wanted no breast scars, and patients who had a poorly defined inframammary fold. The mean follow-up period was 16 months. Implant and incision approach complications were evaluated. Information on patient satisfaction was collected. RESULTS: A total of 14 complications occurred in 42 patients, all of them minor. Axillary incision-related complications occurred in 26% of the patients, as represented by a late axillary subcutaneous band (119%), sensory loss in the inner aspect of the arm (71%), and a hypertrophic scar and small wound dehiscence (71%). No patient presented with capsular contracture, visible rippling, or infection. Most of the patients (93%) were either very satisfied or satisfied with their result, and none regretted the surgery. CONCLUSION: The TBA procedure without endoscopic assistance is a simple and reliable technique for breast augmentation. Most of the complications in this study were minor and predictable. They did not interfere with the aesthetic outcome nor the normal postoperative recovery. With TBA, success depends on patient selection as well as careful intra- and postoperative management.

Tensor fasciae latae perforator flap: minimizing donor-site morbidity in the treatment of trochanteric pressure sores.

BACKGROUND: To report a new technique with less morbidity for coverage of trochanteric defects, an anatomical and clinical study was performed. METHODS: Twenty-four fresh cadavers were dissected. The following parameters were measured: origin, location, number, and length of the perforating vessels. In addition, a clinical study was performed on 21 patients with trochanteric pressure sores. RESULTS: The anatomical study of 24 fresh cadavers revealed the constant presence of perforator pedicles anterior to the greater trochanter, which provides an adequate arc of rotation arc for flap harvest without sacrificing the underlying muscles. The mean length of the pedicles was 9.59 +/- 2.16 cm. This flap is nourished by perforator vessels arising from the ascending branch of the lateral circumflex femoral artery, which arises from the deep femoral artery and runs through the intermuscular septum, tensor fasciae latae, and rectus femoralis muscles. In this study, flaps were raised based on perforators located preoperatively using a unidirectional Doppler probe. Good results were obtained with primary closure of the donor site, with only two donor-site dehiscences. CONCLUSIONS: This flap is an alternative to myocutaneous flaps, as it preserves local musculature without functional sequelae in patients who walk. It also preserves the local musculature in the event of recurrence, as is usually seen in paralytic patients with pressure sores.