Search Results (31)

Background and Clinical Significance: Breast reconstruction following mastectomy is a critical aspect of treatment for many patients, offering both physical and psychological benefits. Traditional methods include autologous tissue flaps and implants, with implant-based techniques being the most prevalent in the Western world. However, complications such as capsular contracture remain a concern. Acellular dermal matrices (ADM) have emerged as a valuable alternative, improving outcomes by reducing capsular contracture rates and enhancing tissue integration. Case Presentation: This case report presents the first use of a novel ADM, biocade^® (biotrics bioimplants AG, Berlin, Germany) in breast reconstruction following a mastectomy. A 55-year-old female patient underwent a left-sided nipple-sparing mastectomy, followed by prepectoral direct-to-implant reconstruction using an ADM-wrapped implant. The patient tolerated the procedure well, with no immediate complications observed. Postoperative monitoring focused on wound healing and assessing for signs of complications related to the implant. The use of the ADM resulted into satisfactory aesthetic and functional outcomes. Conclusions: The successful outcome of this case highlights the potential benefits of using collagen matrices in breast reconstruction, particularly in preserving mastectomy scenarios. The immediate results and improved aesthetics offered by prepectoral direct-to-implant reconstruction with ADM align well with patient expectations for a more natural appearance and faster recovery. However, this case report also highlights the need for ongoing research to fully explore the potential of these biomaterials and address associated challenges. Full article

Background: Implant-based breast reconstruction (IBBR) is a widely adopted technique following mastectomy in breast cancer patients. However, the impact of chemotherapy type and duration on the development of capsular contracture remains unclear. Methods: This nationwide, retrospective, cohort study used Health Insurance Review and Assessment Service data to identify breast cancer patients who received chemotherapy and underwent immediate IBBR between January 2015 and December 2018. Follow-up continued until January 2024, with a median follow-up of 5.2 years. A total of 4303 patients (direct-to-implant [DTI], n = 2083; tissue expander insertion [TEI], n = 2220) were included. Results: Chemotherapy type and duration were not significantly associated with capsular contracture risk in either the DTI or TEI groups. In the DTI cohort, no significant difference in contracture incidence was found between neoadjuvant and adjuvant chemotherapy before or after matching (p = 0.056 and p = 0.121, respectively). In the TEI cohort, an initially significant difference (p = 0.019) was no longer observed after matching (p = 0.213). Similarly, chemotherapy duration (≤12 weeks vs. >12 weeks) did not impact contracture risk in either cohort. Multivariate analysis identified age, radiotherapy, lymphedema, and axillary lymph node dissection (ALND) as independent risk factors for contracture (p < 0.005). Comorbidities, such as diabetes and autoimmune diseases, also showed no significant association with contracture risk. Conclusions: These findings suggest that chemotherapy decisions should not be guided by contracture concerns. Instead, optimizing reconstruction outcomes should focus on modifiable factors, such as radiotherapy, lymphedema, and ALND. Full article

Several postmastectomy breast reconstruction techniques and procedures have been implemented, although with limited evaluation of benefits and adverse effects. We conducted a systematic review on the plane and timing of reconstruction, and on the use of nipple-sparing mastectomy, acellular dermal matrix, and autologous fat grafting as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). Both immediate and delayed reconstruction may be considered, with preferred timing depending on factors such as patient preferences, type of mastectomy, skin perfusion, comorbidities, pre-mastectomy breast size, and desired reconstructive breast size. Immediate reconstruction may provide greater psychological or quality of life benefits. In patients who are candidates for skin-sparing mastectomy and without clinical, radiological, and pathological indications of nipple-areolar complex involvement, nipple-sparing mastectomy is recommended provided it is technically feasible and acceptable aesthetic results can be achieved. Surgical factors including incision location are important to reduce necrosis by preserving blood supply and to minimize nerve damage. There is a role for both prepectoral and subpectoral implants; risks and benefits will vary, and decisions should be made during consultation between the patient and surgeons. In patients who are suitable candidates for implant reconstruction and have adequate mastectomy flap thickness and vascularity, prepectoral implants should be considered. Acellular dermal matrix (ADM) has led to an increased use of prepectoral reconstruction. ADM should not be used in case of poor mastectomy flap perfusion/ischemia that would otherwise be considered unsuitable for prepectoral reconstruction. Care should be taken in the selection and handling of acellular dermal matrix (ADM) to minimize risks of infection and seroma. Limited data from small studies suggest that prepectoral reconstruction without ADM may be feasible in some patients. Autologous fat grafting is recommended as a treatment for contour irregularities, rippling following implant-based reconstruction, and to improve tissue quality of the mastectomy flap after radiotherapy. Full article

Background/Objectives: Hybrid breast reconstruction (HBR), combining implant-based breast reconstruction (IBR) with autologous fat grafting (FG), has emerged as a promising solution to improve aesthetic outcomes and reduce complications, especially in irradiated patients. This study aims to systematically review current evidence on the outcomes of HBR with a focus on complication rates and aesthetic satisfaction. Methods: A systematic literature search was performed in March 2023 using PubMed and Embase databases. Studies were selected based on predefined PICOS criteria, including adult female patients undergoing IBR with FG. Sixteen studies met the inclusion criteria. Data on patient demographics, surgical techniques, fat grafting timing, complications, and aesthetic outcomes were extracted and analysed. Results: A total of 730 patients were included, with a mean follow-up of 20.23 months. The overall complication rate was 9%, with fat necrosis being the most common (2.7%). Capsular contracture occurred in 4.5% of cases. Immediate fat grafting during implant placement showed the lowest complication rate (8%) compared to delayed or staged procedures. Aesthetic satisfaction was high, with an average score of 4.4 out of 5 in five studies. Fat grafting improved skin quality and contour, especially in irradiated patients, and enabled the use of smaller implants. No oncological recurrences were reported. Conclusions: HBR is associated with high aesthetic satisfaction and a low rate of complications. Immediate fat grafting during IBR appears to be the safest and most effective approach. These findings support the wider adoption of HBR, though further high-quality studies are needed to validate long-term safety and outcomes. Full article

Background/Objectives: Immediate implant-based breast reconstruction is an established option for selected patients undergoing mastectomy. However, patients with large and ptotic breasts present specific reconstructive challenges, often requiring tailored approaches to minimize complications and optimize aesthetics. This pilot study aimed to evaluate the clinical feasibility and effectiveness of a mobile application developed to support intraoperative decision-making based on an institutional algorithm for breast reconstruction. It is also important to underline that this pilot study was exploratory in nature and primarily aimed at assessing feasibility and adherence to an app-based decision pathway, rather than comparative efficacy. Methods: We conducted a prospective observational study from October 2023 to December 2024 at the University Hospital of Sassari. Female patients with large and ptotic breasts undergoing immediate implant-based reconstruction were included. A mobile app, developed using MIT App Inventor 2, implemented our institution’s algorithm and guided surgeons through both preoperative and intraoperative decision-making. Surgical options included subpectoral, prepectoral with autologous fascial flaps, or prepectoral with acellular dermal matrix (ADM) reconstruction, depending on flap thickness and fascia integrity. Results: Sixteen patients (21 reconstructed breasts) were included. Surgical planning and execution followed app-generated recommendations in all cases, with no intraoperative deviations. Subpectoral reconstruction was performed in six patients, prepectoral with ADM in eight, and prepectoral with fascial flaps in two. The app was rated positively by all surgeons and facilitated consistent decision-making. Conclusions: The proposed mobile application, described in this pilot study, proved to be a feasible and effective decision-support tool for implant-based breast reconstruction in patients with challenging anatomy. It standardized surgical choices, supported training, and has the potential to enhance reproducibility and safety in complex reconstructive procedures. Full article

Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed—with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results. Full article

Background: Few studies have compared the risk of reoperation by timing in breast reconstruction surgery after mastectomy. We evaluated the first and total number of reoperations by reconstruction timing in women with breast cancer undergoing primary mastectomy. Methods: A cohort study of 23,301 primary mastectomies in women with breast cancer undergoing either immediate breast reconstruction (IBR) or delayed reconstruction was carried out within Kaiser Permanente between 2010 and 2022. The first reoperation rate was calculated using cause-specific Cox Proportional Hazards Models, while Multiplicative Cox Proportional Hazards Models were used to account for mortality and timing in reoperation. Patients were continuously monitored for death, outcome of interest, loss to follow-up through healthcare membership termination, or study end date (31 December 2022). Results: In total, 78.4% (n = 18,276) of the cohort underwent IBR. The average follow-up time was 5.9 years (±3.8). The following covariates were imbalanced (standardized mean difference [SMD] ≥ 0.20) between IBR and delayed groups: BMI, smoking status, year of mastectomy, bilateral procedures, and reconstruction type. The crude incidence of first reoperation was 33.04% vs. 31.72% in IBR vs. delayed patients and the risk of reoperation was 18% higher in IBR patients (HR = 1.18, 95% CI = 1.12–1.25). There was no difference in the risk of reoperation by timing (p > 0.05) when assessing multiple reoperations. The reoperation risk was the highest for IBR patients who did not complete reconstruction or single-stage reconstruction. In addition, the first reoperation rate of IBR patients was higher in those who underwent expander–implant-based reconstruction. Conclusions: The first reoperation rate was higher in IBR patients compared to those who delayed reconstruction, although we failed to detect a difference for multiple returns to surgery, except in certain subgroups. Assessing reoperation risk by timing among different reconstruction modalities can aid patients in making informed decisions about the type of breast reconstruction to undergo. Full article

Background: Women undergoing a mastectomy often suffer severely from the sequelae of losing one or both breasts. Implant-based breast reconstruction restores female body integrity but can result in significant postoperative pain. The use of paravertebral catheters has been shown to aid significantly in pain management during the postoperative recovery. However, the vasodilation that is induced by paravertebral blocks may lead to prolonged drainage fluid secretion, blood loss and increased likelihood of revision surgery. Therefore, we analyzed the effects of paravertebral blocks after combined mastectomy and immediate breast reconstruction. Methods: We analyzed 115 breast surgeries at the department of Plastic Surgery at the University clinic of St. Poelten between 1 August 2018 and 31 December 2022. Patients were analyzed regarding postoperative hemoglobin loss and drainage fluid volumes and their correlation with paravertebral blocks. Statistical analyses were performed using Levene’s Test for Equality of Variances within our cohort. Results: The postoperative hemoglobin loss did not differ significantly between our groups (p = 0.295). Furthermore, a paravertebral block did not increase the amount of postoperative drainage fluid volumes (p = 0.508). Women receiving paravertebral blocks also did not stay longer in hospitals (p = 0.276). No paravertebral block-associated complication was seen. Conclusions: In this study, we demonstrated paravertebral blocks to be safe adjuncts in breast reconstruction to minimize pain without leading to increased blood loss or seroma formation. This indicated that vasodilatation induced by paravertebral blocks did not negatively influence the postoperative recovery. In conclusion, postoperative pain management using paravertebral blocks can be a beneficial therapeutic adjunct in surgical management of breast cancer patients. Full article

Background: Negative Pressure Wound Therapy (NPWT) has proven to be an effective intervention in preventing postoperative complications across a range of surgical specialties, including orthopedics, vascular, and abdominal surgery. This study aimed to assess the prophylactic use of NPWT dressing compared to the Standard of Care (SOC) in high-risk patients undergoing oncoplastic and reconstructive breast surgery. Materials and Methods: This preliminary case-control study included 23 high-risk patients, enrolled between September 2023 and February 2024, at San Martino Polyclinic Hospital, Genoa. High-risk patients were defined as those with one or more of the following risk factors: obesity, prior radiotherapy, neoadjuvant chemotherapy, smoking history, diabetes, or corticosteroid use. The surgical procedures evaluated in this study included mastectomy with immediate implant-based breast reconstruction, reduction mammoplasty, and oncoplastic breast surgery following local excision or quadrantectomy. NPWT dressing was applied immediately after skin closure in the operating room, replaced after 2–3 days, and removed 7 days post-procedure. Surgical outcomes assessed included skin flap necrosis, wound dehiscence, infection, implant loss, and delays in adjuvant therapy. Results: A total of 23 patients, aged 45 to 57 years, were enrolled. Eleven patients received NPWT dressing, while twelve were treated with SOC. No complications occurred in the NPWT dressing group, whereas four complications were observed in the SOC group. Of the control group, three patients developed infections, which were treated with oral antibiotics for two, while one required implant replacement surgery. The remaining patient in the control group experienced wound dehiscence, which was successfully managed conservatively on an outpatient basis. Discussion and Conclusions: Our findings suggest that prophylactic NPWT dressing in oncoplastic and reconstructive breast surgery results in a significantly lower rate of wound-related complications. Although this is a preliminary study, it provides a foundation for further research in a larger cohort. These results also prompt a discussion of the cost-effectiveness of NPWT dressing relative to the SOC, given its higher cost. Full article

Objectives: this study aimed to evaluate the evolution of planned dose distribution quality in two groups of breast cancer patients treated with hypofractionated intensity-modulated radiotherapy (IMRT) using Helical TomoTherapy^® at our institute 5 years apart. Methods: the analysis included two cohorts of patients who underwent implant-based immediate breast reconstruction (IBR) and received post-mastectomy IMRT to the chest wall and infra/supraclavicular lymph nodes, following a 15-fraction regimen (2.67 Gy per fraction). The first group was treated between 2012 and 2015, while the second received treatment between 2019 and 2020. Dosimetric indices derived from dose–volume histograms used in clinical practice were analyzed to assess dose distribution quality. A quantitative scoring system was applied retrospectively to compare the two groups in terms of target coverage and organ-at-risk (OAR) sparing. Additionally, capsular contracture (CC) incidence was examined in both cohorts. Results: A total of 240 patients were included in the study. The percentage of optimal treatment plans increased from 70.8% in the 2012–2015 cohort to 77.5% in the 2019–2020 cohort, while compromised plans decreased from 10.8% to 7.5%. Furthermore, the incidence of moderate-to-severe CC dropped from 54.8% in the earlier cohort to 43.5% in the later one. Conclusions: Helical Tomotherapy^® has demonstrated the ability to achieve a high rate of optimal treatment plans concerning both PTV coverage and OAR sparing in a challenging population of postmastectomy patients with IBR. The learning curve showed that, after 5 years, the rate of optimal plans was increased, accompanied by a reduction in compromised plans and treatment-related toxicity. Full article

Background: Macromastia is a well-known issue in breast reconstruction. Skin-reducing mastectomy (SRM) was introduced as a skin-sparing mastectomy that utilizes a skin reduction pattern similar to breast reduction or breast lift surgery, specifically to manage hypertrophic and pendulous breasts. Over time, numerous authors have contributed to refining the SRM technique, leading to the development of various technical variants. However, the diversity of approaches inspired by SRM has created confusion, and clear surgical indications are lacking. Methods: We propose a unifying concept called breast reshaping mastectomy (BRM), which encompasses all techniques based on SRM principles. The BRM aims not only to preserve and reduce the breast skin envelope but also to immediately reshape it for a more aesthetic outcome. This approach is applicable to all mastectomies where skin envelope preservation (with or without the nipple-areola complex) is oncologically safe, a modification of breast skin coverage is needed for better aesthetic results, and an implant-based reconstruction is planned. Results: To define the BRM concept, we reviewed the existing literature on SRM and its related techniques. Our analysis focused on four key elements: skin incision pattern, implant coverage strategy, nipple-areola complex (NAC) management, and the choice between two-stage and direct-to-implant reconstruction. Conclusions: By integrating these four components into a single surgical framework, BRM provides a structured approach to breast reconstruction that enhances both oncologic safety and aesthetic outcomes. Standardizing these techniques could help clarify surgical indications and improve reconstructive planning for patients undergoing skin-sparing mastectomy. Full article

Background/Objectives: Implant-based breast reconstruction (IBBR) is increasingly favored over autologous reconstruction due to its procedural simplicity and recovery benefits. Conducting this reconstruction using either the subpectoral or prepectoral planes has varied aesthetic outcomes. This study utilizes VECTRA XT 3D imaging to objectively assess breast symmetry differences between these surgical techniques. Methods: A retrospective cohort study was conducted analyzing data from patients undergoing unilateral total mastectomy followed by immediate silicone implant reconstruction via subpectoral or prepectoral techniques. The VECTRA XT 3D system provided measurements, including sternal-notch-to-nipple (SN-N), midline-to-nipple (ML-N), and nipple-to-inframammary fold (N-IMF) distances, as well as breast width, volume, and projection, taken more than a year postoperatively, to assess symmetry and aesthetic outcomes. Results: The study included 63 patients—29 in the subpectoral group and 38 in the prepectoral group. The SN-N ratio was 0.91 for the subpectoral group compared to 0.95 for the prepectoral group (p = 0.014). Among patients with a BMI of 25 or higher, the prepectoral group had an SN-N ratio significantly closer to 1 (0.97 ± 0.07) than the subpectoral group (0.89 ± 0.06) (p = 0.027). No statistically significant differences were found in metrics based on the surgical method across age categories divided at 50. Conclusions: The prepectoral IBBR technique shows improved nipple positioning and breast symmetry compared to subpectoral methods, as assessed via precise 3D imaging. This finding suggests potential advantages for surgical planning and patient satisfaction, indicating the need for large cohort studies to further investigate the factors influencing breast symmetry. Full article

Background/Objectives: As breast reconstruction techniques continue to progress, patient satisfaction with aesthetic outcomes has become an increasingly important marker of success. Obtaining optimal symmetry often requires secondary procedures whether reconstruction is unilateral or bilateral, implant-based or autologous, immediate or delayed. Consequently, determining the ideal method to achieve symmetry, particularly in challenging scenarios, such as the radiated breast, is nuanced and requires experienced decision-making. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines, including the PubMed, Cochrane Library, and Embase bibliographic databases, to identify original articles addressing asymmetry in both implant-based and autologous breast reconstruction. Studies based on benign breast disease or oncoplastic reconstruction for partial mastectomy/lumpectomy defects were excluded. Results: The search initially yielded a total of six hundred and fifty unique articles. After complete assessment of inclusion and exclusion criteria, a total of forty-one articles were included in total. Conclusions: This article provides a systematic review of the current literature available to guide surgeons on managing asymmetry in breast reconstruction and highlights case examples of frequently encountered clinical challenges. A novel treatment algorithm was then generated to serve as a comprehensive decision-making guide for both patients and surgeons. Full article

Background: The reconstruction of large breasts carries a heightened risk profile. While skin-reducing mastectomy (SRM) techniques facilitate the correction of breast ptosis, they are frequently associated with a high incidence of vascular complications. This study compares two SRM techniques—the horizontal incision and the classic inverted T incision—by examining their clinical and surgical outcomes. Methods: We retrospectively analyzed data from 24 patients (30 breasts) who underwent SRM with immediate prosthetic reconstruction between 2019 and 2023 at the European Institute of Oncology in Milan, Italy. Our comparison focused on breast aesthetic outcome, reconstruction quality, complication rates (early and late), and patient satisfaction, utilizing the BREAST-Q questionnaire to gauge the latter. Results: Among the 24 patients included in the study, 16 (20 breasts) were treated with the inverted T technique, and 8 (10 breasts) with the horizontal incision approach. A higher overall complication rate was observed with the inverted T technique compared to the horizontal method, with early complications outnumbering late ones. The most common issues were recurrent seroma and skin necrosis leading to implant exposure. Notably, there were no cases of implant infection. Although the horizontal incision technique achieved slightly higher patient satisfaction scores, the difference was not statistically significant. Discussion: The inverted T and horizontal incision techniques each have unique benefits and drawbacks. Our findings indicate enhanced patient satisfaction and reduced complication rates with the horizontal incision technique. The selection of the technique should be customized based on the patient’s individual risk factors, tissue quality, and preferences. Full article

Following nipple-sparing mastectomy (NSM), patients commonly experience significant impairment or total loss of nipple sensitivity, which negatively impacts the patients’ quality of life, whereas patients who retain nipple sensation postoperatively experience enhanced physical, psychosocial, and sexual well-being. Reinnervation techniques such as nerve allografting have been utilized to retain sensation. Despite the benefits of nerve allografts, such as lack of donor site morbidity, ease of use, and potentially shorter surgery time, there are shortcomings, such as the cost of commercially available acellular nerve allografts, and, most importantly, decreased sensory and motor function recovery for acellular nerve allografts with a diameter greater than 3 mm or a length greater than 50 mm. We present a technique where we performed immediate implant-based breast reconstruction combined with nipple–areola complex reinnervation using an autologous nerve graft. Following the procedure, the patient had improved sensory outcomes in the reconstructed breast and good quality-of-life indices. This report highlights the potential for sural nerve autografts in restoring breast sensation following mastectomy. Full article