Faculty Bibliography

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.

BACKGROUND:Reconstructive trends and outcomes for nipple-sparing mastectomy continue to be defined. The graduated impact of breast size and mastectomy weight remains incompletely evaluated. METHODS:All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified. Demographics and outcomes were analyzed and stratified by mastectomy weight of 800 g or higher (large group), between 799 and 400 g (intermediate group), and less than 400 g (small group). RESULTS:Of 809 nipple-sparing mastectomies, 66 (8.2 percent) had mastectomy weights of 800 g or higher, 328 (40.5 percent) had mastectomy weights between 799 and 400 g, and 415 nipple-sparing mastectomies (51.3 percent) had mastectomy weights less than 400 g. Nipple-sparing mastectomies in the large group were significantly more likely to be associated with major mastectomy flap necrosis (p = 0.0005), complete nipple-areola complex necrosis (p < 0.0001), explantation (p < 0.0001), cellulitis treated with oral (p = 0.0008) and intravenous (p = 0.0126) antibiotics, abscess (p = 0.0254), and seroma (p = 0.0126) compared with those in the intermediate group. Compared with small nipple-sparing mastectomies, patients in the large group had greater major mastectomy flap necrosis (p < 0.0001), complete (p < 0.0001) and partial (p = 0.0409) nipple-areola complex necrosis, explantation (p < 0.0001), cellulitis treated with oral (p < 0.0001) and intravenous (p < 0.0001) antibiotics, abscess (p = 0.0119), and seroma (p < 0.0001). Patients in the intermediate group were more likely to experience major (p < 0.0001) and minor (p < 0.0001) mastectomy flap necrosis, complete (p = 0.0015) and partial (p < 0.0001) nipple-areola complex necrosis, cellulitis treated with oral antibiotics (p = 0.0062), and seroma (p = 0.0248) compared with those undergoing small nipple-sparing mastectomies. Larger mastectomy weights were significant predictors of complications on logistic regression analysis. CONCLUSION/CONCLUSIONS:Reconstructive and ischemic complications in nipple-sparing mastectomy are progressively greater as mastectomy weight and breast size increase. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

Growing public awareness of hereditary breast cancers, notably BRCA1 and BRCA2, and increasing popularity of personalized medicine have led to a greater number of young adult patients presenting for risk-reduction mastectomies and breast reconstruction. Plastic surgeons must be familiar with treatment guidelines, necessary referral patterns, and particular needs of these patients to appropriately manage their care. Genetic testing for BRCA1 and BRCA2 is most often reserved for patients older than the age of consent, and can be performed in the young adult population (aged 18 to 25 years) with the appropriate preemptive genetic counseling. Subsequent risk-reduction procedures are usually delayed until at least the latter end of the young adult age range, and must be considered on an individualized basis with regard for a patient's level of maturity and autonomy. Prophylactic mastectomies in young adults also can serve to aid the unique psychosocial needs of this population, although the long-term psychological and physical ramifications must be considered carefully. With the development of nipple-sparing mastectomy and improvement in reconstructive techniques, risk-reducing surgery has become more accepted in the younger population. Immediate, implant-based reconstruction is a common reconstructive technique in these patients but requires extensive discussion regarding reconstructive goals, the risk of possible complications, and long-term implications of these procedures. Comprehensive, continuous support with multispecialty counseling is necessary throughout the spectrum of care for the high-risk, young adult patient.

BACKGROUND:Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy (NSM) remains controversial. We therefore examined outcomes in NSM with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. METHODS:Autologous free flap reconstructions with NSM performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. RESULTS:221 free flaps for NSM reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. Most common flaps used were deep inferior epigastric perforator (DIEP) (64%), profunda artery perforator (PAP) (12.1%), and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps (10.4%). Autologous reconstructions with a skin paddle had significantly greater BMI (p=0.006). Mastectomy weight (p = 0.017) and flap weight (p<0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0% vs. 2.3%, p=1.000) or percentage of flaps requiring return to the operating room (6.0% vs. 4.7%, p=0.715) between groups. Buried flaps had an absolute greater mean number of revisional procedures per NSM (0.82) compared to the skin paddle group (0.44), however rates of revision procedures per NSM were statistically equivalent between the groups (p=0.296). CONCLUSIONS:While buried free flap reconstruction in NSM has been shown to be safe and effective, our technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision.

Background/UNASSIGNED:While possessing numerous benefits, microsurgical breast reconstruction is associated with longer operative times and post-operative hospital length of stay compared to implant-based reconstruction. We therefore evaluate factors associated with increased length of stay (LOS) after microsurgical breast reconstruction with a case-control study design. Methods/UNASSIGNED:All patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction over a two-year time period were identified. Risk factors associated with LOS greater than or equal to 5 days were identified. Results/UNASSIGNED:A total of 116 patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction were identified. Of these, 86 (74.1%) had a LOS of 4 days or less (mean: 3.70 days) while 30 (25.9%) had a LOS of 5 days or greater (mean: 5.50 days).With regards to patient demographics and intra-operative factors, patients with a LOS of 5 days or greater were significantly more likely to have diabetes mellitus (p < 0.0001), undergo bilateral reconstruction (p = 0.0003) and total mastectomy (p < 0.0001), and have a longer operative time (p < 0.0001) while significantly less likely to undergo post-operative radiation (p = 0.0421). Notably, there was no significant difference between the groups in terms of follow-up time, or time since breast reconstruction (p = 0.0600).With regards to reconstructive complications, patients with LOS of 5 days of greater were significantly more likely to experience abdominal donor site abscess (p < 0.0001), breast hematoma (p = 0.0186), and return to the operating room for flap compromise (p < 0.0001). Conclusions/UNASSIGNED:Multiple patient-specific, intra-operative, and post-operative outcomes factors are associated with increased length of stay with immediate and delayed microsurgical breast reconstruction.

Twenty percent of breast cancer cases may be related to a genetic mutation conferring an increased risk of malignancy. The most common and prominent breast cancer susceptibility genes are BRCA1 and BRCA2, found in nearly 40% of such cases. However, continued interest and investigation of cancer genetics has led to the identification of a myriad of different breast cancer susceptibility genes. Additional genes, each with unique significance and associated characteristics, continue to be recognized. Concurrently, advanced genetic testing, while still controversial, has become more accessible and cost-effective. As oncologic and reconstructive advances continue to be made in prophylactic breast reconstructive surgery, patients may present to plastic surgeons with an increasingly more diverse array of genetic diagnoses to discuss breast reconstruction. It is therefore imperative that plastic surgeons be familiar with these breast cancer susceptibility genes and their clinical implications. We, therefore, aim to review the most common non-BRCA1/2 breast cancer susceptibility genetic mutations in an effort to assist plastic surgeons in counseling and managing this unique patient population. Included in this review are syndromic breast cancer susceptibility genes such as TP53, PTEN, CDH1, and STK11, among others. Nonsyndromic breast cancer susceptibility genes herein reviewed include PALB2, CHEK2, and ataxia telangiectasia mutated gene. With this knowledge, plastic surgeons can play a central role in the diagnosis and comprehensive treatment, including successful breast reconstruction, of all patients carrying genetic mutations conferring increased risk for breast malignancies.

BACKGROUND: The increasing use of autologous fat grafting in breast cancer patients has raised concerns regarding its oncologic safety. This study evaluated patient outcomes and tumor recurrence following mastectomy reconstruction and autologous fat grafting. METHODS: Retrospective chart review identified patients who underwent mastectomy followed by breast reconstruction from 2010 to 2015. Eight hundred twenty-nine breasts met inclusion criteria: 248 (30.0 percent) underwent autologous fat grafting, whereas 581 (70.0 percent) breasts did not. Patient demographics, cancer characteristics, oncologic treatment, surgical treatment, surgical complications, local recurrence, and distant metastases were analyzed. RESULTS: Autologous fat grafting patients and control patients were of similar body mass index, smoking status, and BRCA status. Patients who underwent fat grafting were significantly younger than control patients and were less likely to have diabetes, hypertension, or hyperlipidemia. The two groups represented similar distributions of BRCA status, Oncotype scores, and hormone receptor status. Patients underwent one to four grafting procedures: one procedure in 83.1 percent, two procedures in 13.7 percent, three in 2.8 percent, and four in 0.4 percent. Mean follow-up time from initial surgery was 45.6 months in the fat grafting group and 38.8 months in controls. The overall complication rate following fat grafting was 9.4 percent. Among breasts undergoing surgery for therapeutic indications, there were similar rates of local recurrence (fat grafting group, 2.5 percent; controls, 1.9 percent; p = 0.747). Interestingly, mean time to recurrence was significantly longer in the fat grafting group (52.3 months versus 22.8 months from initial surgery; p = 0.016). CONCLUSIONS: Autologous fat grafting is a powerful tool in breast reconstruction. This large, single-institution study provides valuable evidence-based support for its oncologic safety. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

BACKGROUND: Ischemic complications after nipple-sparing mastectomy (NSM) have been associated with numerous variables. However, the impact of NSM flap thickness has been incompletely evaluated. METHODS: NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre- or postoperative breast magnetic resonance imaging (MRIs). Demographics and outcomes were stratified by those with and without ischemic complications. RESULTS: Of 1,037 NSM reconstructions, 420 NSMs had MRI data available, which included 379 preoperative MRIs and 60 postoperative MRIs. Average total preoperative skin/subcutaneous tissue NSM flap thickness was 11.4 mm. Average total postoperative NSM flap thickness was 8.7 mm. NSMs with ischemic complications were found to have significantly thinner overall postoperative NSM flap thickness compared with those without ischemic complications (P = 0.0280). Average overall postoperative NSM flap thickness less than 8.0 mm was found to be an independent predictor of ischemic complications (odds ratio, 6.5263; P = 0.026). In NSMs with both pre- and postoperative MRIs, the overall average postoperative NSM flap thickness was 68.2% of preoperative measurements. Average overall postoperative NSM flap thickness was significantly less than average overall preoperative NSM flap thickness (P < 0.0001). NSMs with ischemic complications were found to have a significantly lower ratio of overall postoperative to preoperative flap thickness (52.0% versus 74.0%; P < 0.0001). CONCLUSIONS: Ischemic complications after NSM are significantly associated with thinner postoperative NSM flap thickness. Particularly, NSM flap thickness less than 8.0 mm is a positive independent predictor of ischemic complications. The ratio of postoperative to preoperative NSM flap thickness was significantly lower in reconstructions with ischemic complications.