Faculty Bibliography
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124
Examining Length of Hospital Stay after Microsurgical Breast Reconstruction: Evaluation in a Case-Control Study
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.
PMCID:5889468
PMID: 29632768
ISSN: 2169-7574
CID: 3036812
Non-BRCA1/2 Breast Cancer Susceptibility Genes: A New Frontier with Clinical Consequences for Plastic Surgeons
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.
PMCID:5732672
PMID: 29263966
ISSN: 2169-7574
CID: 2892432
Reply to Letter: Breast cancer molecular subtypes and chemotherapy schedules used in neoadjuvant or adjuvant setting may show different effects in nipple-sparing mastectomy [Letter]
PMID: 28582332
ISSN: 1529-4242
CID: 2592012
Determining the Oncologic Safety of Autologous Fat Grafting as a Reconstructive Modality: An Institutional Review of Breast Cancer Recurrence Rates and Surgical Outcomes
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.
PMID: 28841600
ISSN: 1529-4242
CID: 2676552
Nipple-Areola Complex Malposition in Nipple-Sparing Mastectomy: A Review of Risk Factors and Corrective Techniques from Greater Than 1000 Reconstructions
BACKGROUND: Nipple-areola complex (NAC) malposition after nipple-sparing mastectomy (NSM) can be a challenging issue to correct. The current literature is largely limited to smaller series and implant-based reconstructions. METHODS: A retrospective review of all NSMs from 2006 to 2016 at a single institution was performed. Incidence, risk factors and corrective techniques of NAC malposition were analyzed. RESULTS: 1037 cases of NSM were identified, of which 77 (7.4%) underwent NAC repositioning. All were performed in a delayed fashion. The most common techniques included crescentic periareolar excision (25; 32.5%) and directional skin excision (10; 13.0%).Cases requiring NAC repositioning were significantly more likely to have preoperative radiation (p=0.0008), a vertical or Wise pattern incision (p=0.0157), autologous reconstruction (p=0.0219), and minor mastectomy flap necrosis (p=0.0462) (Table 1). Previous radiation (OR=3.6827, p=0.0028), vertical radial mastectomy incisions (OR=1.8218, p=0.0202), and autologous reconstruction (OR=1.77, p=0.0053) were positive independent predictors of NAC repositioning, whereas implant-based reconstruction (OR=0.5552, p<0.0001) was a negative independent predictor of repositioning. BMI (p=0.7104) and adjuvant radiation (p=0.9536), among other variables, were not predictors of NAC repositioning. CONCLUSIONS: NAC malposition after NSM can be successfully corrected with various techniques. Previous radiation, vertical mastectomy incisions, and autologous reconstruction are independently predictive of NAC malposition.
PMID: 28369015
ISSN: 1529-4242
CID: 2521342
Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging
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.
PMCID:5585433
PMID: 28894660
ISSN: 2169-7574
CID: 2701532
Does Smoking History Confer a Higher Risk for Reconstructive Complications in Nipple-Sparing Mastectomy?
History of smoking has been implicated as a risk factor for reconstructive complications in nipple-sparing mastectomy (NSM), however there have been no direct analyses of outcomes in smokers and nonsmokers. All patients undergoing NSM at New York University Langone Medical Center from 2006 to 2014 were identified. Outcomes were compared for those with and without a smoking history and stratified by pack-year smoking history and years-to-quitting (YTQ). A total of 543 nipple-sparing mastectomies were performed from 2006 to 2014 with a total of 49 in patients with a history of smoking. Reconstructive outcomes in NSM between those with and without a smoking history were equivalent. Those with a smoking history were not significantly more likely to have mastectomy flap necrosis (p = 0.6251), partial (p = 0.8564), or complete (p = 0.3365) nipple-areola complex (NAC) necrosis. Likewise, active smokers alone did not have a higher risk of complications compared to nonsmokers or those with smoking history. Comparing nonsmokers and those with a less or greater than 10 pack-year smoking history, those with a > 10 pack-year history had significantly more complete NAC necrosis (p = 0.0114, <0.0001). Those with <5 YTQ prior to NSM trended toward an increased rate of complete NAC necrosis (p = 0.0752). Outcomes for those with a < 10 pack-year smoking history or >5 YTQ prior to NSM were equivalent to those without a smoking history. We demonstrate that NSM may be safely offered to those with a smoking history although a > 10 pack-year smoking history or <5 YTQ prior to NSM may impart a higher risk of reconstructive complications, including complete NAC necrosis.
PMID: 28097778
ISSN: 1524-4741
CID: 2413902
Does the Timing of Chemotherapy Affect Post-Mastectomy Breast Reconstruction Complications?
INTRODUCTION: In this study we evaluated how the timing of chemotherapy for breast cancer affects post-reconstruction complications to determine whether there is an optimal time for breast reconstruction after chemotherapy. PATIENTS AND METHODS: A retrospective review identified 344 breast cancer patients who underwent chemotherapy with mastectomy and autologous/prosthetic reconstruction from 2011 to 2014. A control group of 127 breast cancer patients who underwent mastectomy and autologous/prosthetic reconstruction without chemotherapy was also identified from the same period. The 2 groups were compared and analyzed for differences in demographic characteristics, treatment, and postoperative complication rates. The chemotherapy group was subsequently stratified into 3 subgroups on the basis of the number of days between chemotherapy treatment and reconstructive surgery ( 60 days) for further analysis. RESULTS: Patients who received chemotherapy were followed for an average of 803.4 days (26.4 months) from the time of initial reconstruction (mean time to complication, 43.3 +/- 82.7 days), and experienced an overall greater complication rate compared with control subjects (32.8% vs. 24.4%; P = .078). When complications were divided into minor, major, and reconstructive failure categories, analysis revealed that the chemotherapy group experienced more minor complications than the control group (18% vs. 11%; P = .067). However, there were no statistically significant differences in major complication rates (10.5% vs. 9.4%) and reconstructive failure complication rates (3.8% vs. 2.4%) between the chemotherapy group and control group. Sixty-eight patients (19.8%) underwent surgery within 30 days of chemotherapy, 210 patients (61%) within 30 to 60 days, and 66 patients (19.2%) after 60 days. Of note, patients in the 60 days), time to complication, complication severity, or complication type. Whereas patients who underwent surgery 30 to 60 days from the time of chemotherapy had lower rates of skin necrosis (3.8%) and infection (15.7%) compared with the
PMID: 28336245
ISSN: 1938-0666
CID: 2499612
Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies
BACKGROUND: Nipple-sparing mastectomy permits complete preservation of the nipple-areola complex with excellent aesthetic results and with oncologic safety similar to that associated with traditional mastectomy techniques. However, outcomes have not been directly compared for tissue expander-, immediate implant-, and autologous tissue-based breast reconstruction after nipple-sparing mastectomy. METHODS: All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified at a single institution. Demographics and outcomes were analyzed and compared among different types of breast reconstruction. RESULTS: A total of 1028 nipple-sparing mastectomies were performed. Of these, 533 (51.8 percent) were tissue expander-based, 263 (25.6 percent) were autologous tissue-based, and 232 (22.6 percent) were immediate implant-based reconstructions. Tissue expander-based reconstructions had significantly more minor cellulitis (p = 0.0002) but less complete nipple necrosis (p = 0.0126) and major mastectomy flap necrosis (p < 0.0001) compared with autologous tissue-based reconstructions. Compared to immediate implant-based reconstruction, tissue expander-based reconstructions had significantly more minor cellulitis (p = 0.0006) but less complete nipple necrosis (p = 0.0005) and major (p < 0.0001) and minor (p = 0.0028) mastectomy flap necrosis (p = 0.0059). Immediate implant-based reconstructions had significantly more minor cellulitis (p = 0.0051), minor mastectomy flap necrosis (p = 0.0425), and partial nipple necrosis (p = 0.0437) compared with autologous tissue-based reconstructions. Outcomes were otherwise equivalent among the three groups. CONCLUSIONS: Tissue expander, immediate implant, and autologous tissue breast reconstruction techniques may all be safely offered with nipple-sparing mastectomy. However, reconstructive complications appear to be greater with immediate implant- and autologous tissue-based techniques compared with tissue expander-based reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
PMID: 28538548
ISSN: 1529-4242
CID: 2574852
Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction
BACKGROUND: Patients undergoing implant-based reconstruction in the setting of postmastectomy radiation therapy suffer from increased complications and inferior outcomes compared with those not irradiated, but advances in radiation delivery have allowed for more nuanced therapy. The authors investigated whether these advances impact patient outcomes in implant-based breast reconstruction. METHODS: Retrospective chart review identified all implant-based reconstructions performed at a single institution from November of 2010 to November of 2013. These data were cross-referenced with a registry of patients undergoing breast irradiation. Patient demographics, treatment characteristics, and outcomes were analyzed. RESULTS: Three hundred twenty-six patients (533 reconstructions) were not irradiated, whereas 83 patients (125 reconstructions) received radiation therapy; mean follow-up was 24.7 months versus 26.0 months (p = 0.49). Overall complication rates were higher in the irradiated group (35.2 percent versus 14.4 percent; p < 0.01). Increased maximum radiation doses to the skin were associated with complications (maximum dose to skin, p = 0.05; maximum dose to 1 cc of skin, p = 0.01). Different treatment modalities (e.g., three-dimensional conformal, intensity-modulated, field-in-field, and hybrid techniques) did not impact complication rates. Prone versus supine positioning significantly decreased the maximum skin dose (58.5 Gy versus 61.7 Gy; p = 0.05), although this did not translate to significantly decreased complication rates in analysis of prone versus supine positioning. CONCLUSIONS: As radiation techniques evolve, the maximum dose to skin should be given consideration similar to that for heart and lung dosing, to optimize reconstructive outcomes. Prone positioning significantly decreases the maximum skin dose and trends toward significance in reducing reconstructive complications. With continued study, this may become clinically important. Interdepartmental studies such as this one ensure quality of care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
PMID: 28538549
ISSN: 1529-4242
CID: 2574862
