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The Importance of Tissue Perfusion in Reconstructive Breast Surgery
Frey, Jordan D; Salibian, Ara A; Choi, Mihye; Karp, Nolan S
Immediate breast reconstruction relies on healthy mastectomy flaps for success. Tissue perfusion of these mastectomy flaps is dependent on multiple patient-, operative-, and surgeon-specific factors, which must be optimized. Unfortunately, tissue perfusion is also notoriously difficult to accurately assess and investigate. In this review, we discuss the importance of tissue perfusion in successful reconstructive breast surgery with an emphasis on perfusion assessment and techniques to ensure that anatomic mastectomy flap perfusion is maintained for immediate breast reconstruction after mastectomy. Preoperative and patient-specific factors should be considered with operative plans modified to minimize ischemic risk. Intraoperatively, incision planning and mastectomy dissection will dictate skin flap perfusion. Most importantly, mastectomy dissection in a plane at the breast capsule will maximize preservation of the subdermal plexus and subcutaneous perforators that supply the breast skin envelope while also maximizing oncologic parenchymal resection. Such anatomic dissection has been demonstrated to decrease risk of ischemic complications in immediate breast reconstruction. Postoperatively, any potential or actual areas of impaired perfusion and ischemia must be diagnosed appropriately and managed proactively to ensure a successful reconstruction. It is also important for surgeons to be aware of imaging modalities and adjunctive technologies that can help promote and assess optimal mastectomy flap tissue perfusion. Plastic surgeons and breast surgeons must actively and collaboratively work together to ensure their mutual goals are met, and optimal outcomes are attained for patients undergoing immediate breast reconstruction after mastectomy.
PMID: 31246757
ISSN: 1529-4242
CID: 3963862
Oncologic Trends, Outcomes, and Risk Factors for Locoregional Recurrence: An Analysis of Tumor-to-Nipple Distance and Critical Factors in Therapeutic Nipple-Sparing Mastectomy
Frey, Jordan D; Salibian, Ara A; Lee, Jiyon; Harris, Kristin; Axelrod, Deborah M; Guth, Amber A; Shapiro, Richard L; Schnabel, Freya R; Karp, Nolan S; Choi, Mihye
BACKGROUND:Oncologic outcomes with nipple-sparing mastectomy (NSM) continue to be established. We examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance (TND), in therapeutic NSMs. METHODS:Demographics, outcomes, and overall trends for all NSMs undertaken for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including TND. RESULTS:A total of 496 therapeutic NSMs were performed with average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4%) and ductal carcinoma in situ (50.4%). Sentinel lymph node sampling was performed in 79.8% of NSMs; 4.1% had positive frozen sentinel lymph node biopsies while 15.7% had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5%) followed by Stage 0 (31.3%).Per NSM, the rate of local recurrence was 1.6% (N=8); the rate of regional recurrence was 0.6% (N=3). In all, 171 NSMs had magnetic resonance imaging available to assess tumor-to-nipple distance (TND). NSMs with TND ≤1 centimeter (25.0% versus 2.4%, p=0.0031/p=0.1129) and ≤2 centimeters (8.7% versus 2.0%; p=0.0218/p=0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, TND ≤1 centimeter was the only significant risk factor for recurrence (OR=13.5833, p=0.0385). No factors were significant in regression analysis. CONCLUSIONS:In this group of early stage and in situ breast carcinoma, therapeutic NSM appears oncologically safe with a locoregional recurrence rate of 2.0%. Tumor-to-nipple distances of ≤1 centimeter and ≤2 centimeters trended to higher rates of recurrence.
PMID: 30907805
ISSN: 1529-4242
CID: 3778702
Ischemic Complications after Nipple-sparing Mastectomy: Predictors of Reconstructive Failure in Implant-based Reconstruction and Implications for Decision-making
Salibian, Ara A; Frey, Jordan D; Bekisz, Jonathan M; Karp, Nolan S; Choi, Mihye
Background/UNASSIGNED:Mastectomy flap and nipple-areola complex (NAC) ischemia can be devastating complications after nipple-sparing mastectomy (NSM). Predictors of reconstructive failure with major skin envelope ischemia and implications for decision-making remain to be fully elucidated. Methods/UNASSIGNED:All cases of implant-based reconstruction after NSM from 2006 to June 2018 with mastectomy flap necrosis or NAC necrosis requiring debridement were reviewed. Data on patient demographics, operative characteristics, additional complications, and the nature and management of ischemic complications were collected and analyzed. Results/UNASSIGNED:= 0.0494). Conclusions/UNASSIGNED:NSM cases with major ischemia requiring explantation had a lower body mass index and significantly higher rate of preoperative radiation, immediate implant placement, use of acellular dermal matrix/mesh, and concomitant major infection. These variables should be taken into account when discussing risks with patients preoperatively and assessing the quality of mastectomy flaps and subsequent reconstructive choices intraoperatively.
PMCID:6571321
PMID: 31333984
ISSN: 2169-7574
CID: 3987992
Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions
Frey, Jordan D; Salibian, Ara A; Karp, Nolan S; Choi, Mihye
LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection. SUMMARY/CONCLUSIONS:Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.
PMID: 30688910
ISSN: 1529-4242
CID: 3626402
Optimizing Outcomes in Nipple-sparing Mastectomy: Mastectomy Flap Thickness Is Not One Size Fits All
Frey, Jordan D; Salibian, Ara A; Choi, Mihye; Karp, Nolan S
Nipple-sparing mastectomy (NSM) places greater stress on the breast-skin envelope compared with traditional mastectomy techniques. Precise mastectomy flap dissection is critical to optimize breast skin flap thickness and minimize complication risk. This study evaluated patient-specific factors associated with mastectomy flap quality to improve technical success in NSM. Ideal NSM flap thickness was determined for all NSMs from 2006 to 2016 with available preoperative breast magnetic resonance imaging (MRIs). Demographic, operative variables, and flap thickness were compared for NSMs as stratified by body mass index (BMI) and mastectomy weight. Of the 1,037 NSMs, 420 cases (40.5%; 243 patients) had MRI data available, which included 379 (36.5%) preoperative breast MRIs. Average BMI was 24.08 kg/m2, whereas average mastectomy weight was 442.28 g. NSMs were classified according to BMI <25 kg/m2, 25-30 kg/m2, and >30 kg/m2. Average ideal overall NSM flap thicknesses in these groups were 10.43, 12.54, and 14.91 mm, respectively. Each incremental increase in average overall NSM flap thickness per BMI category was statistically significant (P < 0.0001; P < 0.0001; P = 0.0002). NSMs were also classified into mastectomy weight categories: <400 g, 400-799 g, and ≥800 g. Average overall NSM flap thicknesses in these groups were 9.97, 12.21, and 14.50 mm, respectively. Each incremental increase in average overall NSM flap thickness per mastectomy weight category was similarly statistically significant (P < 0.0001; P < 0.0001; P < 0.0001). NSM flap thickness and quality is related to BMI and breast size. Characterizing these anatomic variations preoperatively will help surgeons optimize mastectomy flap dissections and minimize ischemic complications in breast reconstruction after NSM.
PMCID:6382218
PMID: 30859052
ISSN: 2169-7574
CID: 3733012
Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm
Frey, Jordan D; Salibian, Ara A; Levine, Jamie P; Karp, Nolan S; Choi, Mihye
BACKGROUND:Nipple-sparing mastectomy (NSM) allows for preservation of the entire nipple-areola complex utilizing various incision patterns. Reconstructive trends and overall risk associated with these diverse NSM incisions have yet to be fully elucidated. METHODS:All NSMs from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar. RESULTS:A total of 1212 NSMs were performed with 1207 NSMs included for final analysis. Of these, 638 (52.9%) utilized an inframammary fold incision, 294 (24.4%) utilized a lateral radial incision, 161 (13.3%) used a vertical radial incision, 60 (5.0) utilized a Wise pattern incision, 35 (2.9%) used a previous incision, and 19 (1.6%) utilized a periareolar incision.The groups were heterogeneous and differed significantly with regards to various factors including age (p<0.001), body-mass index (p<0.001), mastectomy indication (p<0.001), mastectomy laterality (p<0.001), pathologic cancer stage (p<0.001), reconstruction modality (p<0.001), and adjuvant chemoradiation (p=0.031; p=0.002), among others.In crude multivariate logistic regression analysis, vertical radial (16.1%) and inframammary fold incisions (21.0%) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p=0.001) emerged as significantly protective of overall complications after controlling all variables. Wise pattern incisions increased the odds of complications, although not quite significantly (p=0.051). CONCLUSIONS:NSM may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with lowest complications while Wise pattern incisions may increase risk.
PMID: 30204677
ISSN: 1529-4242
CID: 3278242
Reply to Letter, Re: Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes [Letter]
Cohen, Oriana; Karp, Nolan; Choi, Mihye
PMID: 30036340
ISSN: 1529-4242
CID: 3216302
Transversus Abdominis Plane Blocks in Microsurgical Breast Reconstruction: Analysis of Pain, Narcotic Consumption, Length of Stay, and Cost
Salibian, Ara A; Frey, Jordan D; Thanik, Vishal D; Karp, Nolan S; Choi, Mihye
BACKGROUND:Transversus abdominis plane blocks are increasingly being used in microvascular breast reconstruction. The implications of these blocks on specific reconstructive, patient, and institutional outcomes remain to be fully elucidated. METHODS:Patients undergoing abdominally based microvascular breast reconstruction from 2015 to 2017 were reviewed. Length of stay, complications, narcotic consumption, donor-site pain, and hospital expenses were compared between patients who did and did not receive transversus abdominis plane blocks with liposomal bupivacaine. Outcomes were subsequently compared in patients with elevated body mass index. RESULTS:Fifty patients (43.9 percent) received blocks [27 (54.0 percent) under ultrasound guidance] and 64 patients (56.1 percent) did not. Patients with the blocks had significantly decreased oral and total narcotic consumption (p = 0.0001 and p < 0.0001, respectively) and significantly less donor-site pain (3.3 versus 4.3; p < 0.0001). There was no significant difference in hospital expenses between the two cohorts ($21,531.53 versus $22,050.15 per patient; p = 0.5659). Patients with a body mass index of 25 kg/m or greater who received a block had a significantly decreased length of stay (3.8 days versus 4.4 days; p = 0.0345) and decreased narcotic consumption and postoperative pain compared with patients without blocks. Patients with a body mass index less than 25 kg/m did not have a significant difference in postoperative pain, narcotic consumption, or length of stay between groups. CONCLUSIONS:Transversus abdominis plane blocks with liposomal bupivacaine significantly reduce oral and total postoperative narcotic consumption and donor-site pain in all patients after abdominally based microvascular breast reconstruction without increasing hospital expenses. The blocks also significantly decrease length of stay in patients with a body mass index greater than or equal to 25 kg/m. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.
PMID: 29879000
ISSN: 1529-4242
CID: 3256962
Risk Factors for Delays in Adjuvant Chemotherapy Following Immediate Breast Reconstruction
Cohen, Oriana; Lam, Gretl; Choi, Mihye; Ceradini, Daniel; Karp, Nolan
BACKGROUND:Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, we determine how post-operative complications impact chemotherapy timing, and identify factors associated with greater risk for delays. METHODS:Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of post-operative complications and time to chemotherapy. RESULTS:A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86%) reconstructions did not experience post-operative complications, 34 (13.9%) did. Patients who experienced post-operative complications had a higher mean age (53.6 vs. 48.1 years, p=0.002), and higher rates of diabetes (23.5% vs. 3.8%, p<0.001).The complication group had delays in initiation of chemotherapy (56 vs. 45 days, p=0.017). Only the immediate autologous reconstruction subgroup demonstrated a statistically significant delay in initiation of chemotherapy.Patients who initiated chemotherapy >48.5 days were of higher mean age (55.9 vs. 50.7 years, p=0.074), had increased rates of diabetes (36.8% vs. 6.7%, p=0.053), and immediate autologous reconstruction (31.6% vs. 0%, p=0.027). A predictive model based on these findings determined that patients with at least 1 of these 3 risk factors have a 74% chance of experiencing prolonged times to chemotherapy initiation vs. 18% without risk factors (p=0.003). CONCLUSIONS:Risk factors for delayed chemotherapy in the context of post-operative complications are age >51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration and counseling.
PMID: 29782396
ISSN: 1529-4242
CID: 3129752
Comparing Therapeutic versus Prophylactic Nipple-Sparing Mastectomy: Does Indication Inform Oncologic and Reconstructive Outcomes?
Frey, Jordan D; Salibian, Ara A; Karp, Nolan S; Choi, Mihye
BACKGROUND:Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. METHODS:Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. RESULTS:A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). CONCLUSIONS:Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.
PMID: 29794639
ISSN: 1529-4242
CID: 3215962