Alex M. Lin

Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends.

Background: Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast cancer. Few data exist on risk factors for complications and reconstruction outcomes. Methods: A single-institution retrospective review was performed between 2007 and 2012. Results: Two hundred eighty-five patients underwent 500 nipple-sparing mastectomy procedures for breast cancer (46 percent) or risk reduction (54 percent). The average body mass index was 24, and 6 percent were smokers. The mean follow-up was 2.17 years. Immediate breast reconstruction (reconstruction rate, 98.8 percent) was performed with direct-to-implant (59 percent), tissue expander/implant (38 percent), or autologous (2 percent) reconstruction. Acellular dermal matrix was used in 71 percent and mesh was used in 11 percent. Seventy-seven reconstructions had radiotherapy. Complications included infection (3.3 percent), skin necrosis (5.2 percent), nipple necrosis (4.4 percent), seroma (1.7 percent), hematoma (1.7 percent), and implant loss (1.9 percent). Positive predictors for total complications included smoking (OR, 3.3; 95 percent CI, 1.289 to 8.486) and periareolar incisions (OR, 3.63; 95 percent CI, 1.850 to 7.107). Increasing body mass index predicted skin necrosis (OR, 1.154; 95 percent CI, 1.036 to 1.286) and preoperative irradiation predicted nipple necrosis (OR, 4.86; 95 percent CI, 1.0197 to 23.169). An inframammary fold incision decreased complications (OR, 0.018; 95 percent CI, 0.0026 to 0.12089). Five-year trends showed increasing numbers of nipple-sparing mastectomy with immediate reconstruction and more single-stage versus two-stage reconstructions (p < 0.05). Conclusions: Nipple-sparing mastectomy reconstructions have a low number of complications. Smoking, body mass index, preoperative irradiation, and incision type were predictors of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Breast reconstruction outcomes after nipple-sparing mastectomy and radiation therapy.

Background: Few studies in the literature examine outcomes of immediate breast reconstruction after mastectomy with nipple preservation and radiation therapy. Methods: Retrospective analysis of multisurgeon consecutive implant-based reconstructions after nipple-sparing mastectomy from June of 2007 to December of 2012 was conducted at a single institution. Results: Six hundred five immediate breast reconstructions were performed following nipple-sparing mastectomy, of which 88 were treated with radiation therapy. There was a trend toward more complications in patients with radiation (19.3 percent versus 12.8 percent; p = 0.099) associated with a higher rate of implant loss (6.8 percent versus 1.0 percent; p = 0.001). Preoperative radiotherapy had a higher risk of total complications (p = 0.04; OR, 2.225; 95 percent CI, 1.040 to 4.758) and postoperative radiotherapy had a higher risk of explantation (p = 0.015; OR, 5.634; 95 percent CI, 1.405 to 22.603). There were no significant differences in nipple removal secondary to malposition or positive oncologic margins in patients with radiation compared to those without radiation. Patients with radiation did have a higher incidence of secondary procedures for capsular contracture (12.5 percent versus 2.3 percent; p < 0.001) and fat grafting (13.6 percent versus 3.9 percent; p < 0.001). The total nipple retention rate in patients with radiation therapy was 90 percent (79 of 88), and the reconstruction failure rate was 8 percent. Conclusions: Nipple-sparing mastectomy and immediate reconstruction in patients who had or will receive radiation therapy is associated with a higher incidence of complications and operative revisions compared with patients without radiation. However, most patients have successful reconstructions with nipple retention and no recurrences. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Assessment of Patient Factors, Surgeons, and Surgeon Teams in Immediate Implant-based Breast Reconstruction Outcomes

Background: Outcome studies of immediate implant-based breast reconstruction have focused largely on patient factors, whereas the relative impact of the surgeon as a contributing variable is not known. As the procedure requires collaboration of both a surgical oncologist and a plastic surgeon, the effect of the surgeon team interaction can have a significant impact on outcome. This study examines outcomes in implant-based breast reconstruction and the association with patient characteristics, surgeon, and surgeon team familiarity. Methods: A retrospective review of 3142 consecutive implant-based breast reconstruction mastectomy procedures at one institution was performed. Infection and skin necrosis rates were measured. Predictors of outcomes were identified by unadjusted logistic regression followed by multivariate logistic regression. Surgeon teams were grouped according to number of cases performed together. Results: Patient characteristics remain the most important predictors for outcomes in implant-based breast reconstruction, with odds ratios above those of surgeon variables. The authors observed significant differences in the rate of skin necrosis between surgical oncologists with an approximately two-fold difference between surgeons with the highest and lowest rates. Surgeon teams that worked together on fewer than 150 procedures had higher rates of infection. Conclusions: Patient characteristics are the most important predictors for surgical outcomes in implant-based breast reconstruction, but surgeons and surgeon teams are also important variables. High-volume surgeon teams achieve lower rates of infection. This study highlights the need to examine modifiable risk factors associated with optimum implant-based breast reconstruction outcomes, which include patient and provider characteristics and the surgical team treating the patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Nipple-sparing mastectomy in patients with previous breast surgery: comparative analysis of 775 immediate breast reconstructions.

Background: An increasing number of women are candidates for nipple preservation with mastectomy. It is unclear how previous breast surgery impacts nipple-sparing mastectomy and immediate breast reconstruction. Methods: A single-institution retrospective review was performed between June of 2007 and June of 2013. Results: Four hundred forty-four patients underwent 775 immediate breast reconstructions after nipple-sparing mastectomy. Of these, 160 patients and 187 reconstructions had previous breast surgery, including 154 lumpectomies, 27 breast augmentations, and six reduction mammaplasties. Two hundred eighty-four patients with 588 reconstructions without previous breast surgery served as the control group. The previous breast surgery patients were older (49.6 years versus 45.8 years; p < 0.001) but otherwise had similar demographics. Previous breast surgery reconstructions were more often unilateral, therapeutic, and associated with preoperative radiotherapy (p < 0.001 for each). Extension of breast scars was common with previous breast surgery, whereas the inframammary incision was most frequent if no scars were present (p < 0.001). Multivariate regression analysis showed that previous breast surgery was not a significant risk factor for ischemic complications or nipple loss. Subgroup analysis showed extension of prior irradiated incisions was predictive of skin flap necrosis (OR, 9.518; p = 0.05). A higher number of lumpectomy patients had preoperative radiotherapy (41 versus 11; p < 0.001), and patients with breast augmentation had more single-stage reconstructions (85.2 percent versus 62.9 percent; p = 0.02). Conclusion: Nipple-sparing mastectomy and immediate reconstruction can be performed in patients with prior breast surgery with no significant increase in nipple loss or ischemic complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Nipple Loss following Nipple-Sparing Mastectomy.

BACKGROUND Nipple preservation at the time of mastectomy is increasingly performed to enhance the overall result from the reconstruction. Unfortunately, some of these patients may lose their nipples for oncologic reasons or because of necrosis. Several studies have investigated risk factors associated with nipple loss, but few data exist on the incidence of cancer in the nipple specimen, nipple removal for cosmesis or symmetry, and whether these patients subsequently pursue nipple reconstruction. METHODS A retrospective review was performed on nipple-sparing mastectomies and immediate reconstruction from 2007 to 2013. RESULTS Of 443 patients (775 breasts), 51 nipples (6.6 percent) were removed. Of the 51 nipple losses, 76 percent had total nipple or nipple-areola complex loss and 24 percent had partial loss. Twenty-five of the nipples (49 percent) required excision for oncologic reasons, 18 nipples (35 percent) were either partially or totally lost because of necrosis, and one nipple (2 percent) was excised for cosmetic reasons. In cases of bilateral reconstruction and unilateral nipple loss, 65 percent of contralateral normal nipples were retained and 35 percent (n = 7) were removed for symmetry. Fourteen nipples had residual cancer or atypia, whereas 37 had normal pathologic findings. Twenty-one nipples (40 percent) were reconstructed and 30 were not. CONCLUSIONS In this series, the incidence of nipple loss following nipple-sparing mastectomy was 6.6 percent and related primarily to positive oncologic margins. The rate of removal for cosmesis was low, suggesting that for most patients the nipple lies in an acceptable position. After removal, 40 percent of patients had nipple reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Revisions in Implant-based Breast Reconstruction: How Does Direct-to-implant Measure Up?

Background: Immediate direct-to-implant breast reconstruction is increasingly performed for breast cancer treatment or prevention. The advantage over traditional tissue expander/implant reconstruction includes the potential for fewer surgical procedures. Methods: Retrospective, single-institution, three-surgeon review identified patients undergoing implant-based reconstruction from 2006 to 2011. Results: Six hundred eighty-two reconstructions were performed in 432 women with an average follow-up of 5 years. Four hundred sixty-five were direct-to-implant reconstructions with acellular dermal matrix while 217 were tissue expander/implant reconstructions without acellular dermal matrix. The overall revision rate in direct-to-implant reconstruction was 20.9 percent. There was no difference in total revision rates between direct-to-implant and tissue expander reconstruction (20.9 percent versus 20.3 percent; p = 0.861). Subgroup analysis showed no difference in revision for malposition (3.4 percent versus 5.5 percent; p = 0.200), size change (6.7 percent versus 5.5 percent; p = 0.569), fat grafting (8.6 percent versus 9.7 percent; p = 0.647), or capsular contracture (4.5 percent versus 3.2 percent; p = 0.429). Multivariable logistic regression analysis showed complications were associated with higher rates of revision for malposition or size in both groups (OR, 2.8; 95 percent CI, 1.56 to 5.13; p = 0.001). Smoking, preoperative irradiation, skin necrosis, and one surgeon were associated with higher rates of fat grafting, whereas increasing body mass index was associated with lower rates. Postoperative radiotherapy and hematoma were predictive of revision for capsular contracture. Conclusions: The 5-year revision rate in this series of direct-to-implant reconstruction was approximately 21 percent and similar to the revision rate in tissue expander/implant reconstruction. Surgical complications, radiotherapy, and the surgeon influenced the rate of revision similarly in both groups. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Health-Related Quality of Life Outcomes in Digital Replantation versus Revision Amputation

Background Earlier, digit viability judged the success of digital replantation. Now, utility health‐related quality of life (HRQOL) measures can better assess the impact of digital replantation. Methods Overall, 264 digital injury patients were sent a regimen of utility measures: Disabilities of the Arm, Shoulder and Hand (DASH) score, European Quality of Life 5 Dimensions, visual analog scale (VAS), time trade‐off (TTO), and standard gamble (SG). Overall, 51 patients responded completely to all of these—36 replantation patients and 15 revision amputation patients. The utility results of these patients were stratified between replantation versus revision amputation; dominant hand replantation versus nondominant hand replantation; and dominant hand revision amputation versus nondominant hand revision amputation. Results The mean VAS score of replant (0.84) and revision amputation (0.75) groups was significantly different (p = 0.05). The mean DASH score of dominant hand replantations (29.72) and nondominant hand replantations (17.97) was significantly different (p = 0.027). The dominant hand revision amputation had higher anxiety levels in comparison to nondominant hand revision amputation (p = 0.027). Patients with two or more digits replanted showed a significant decrease in VAS, TTO, and SG scores in comparison to patients who only had one digit replanted (p = 0.009, 0.001, and 0.001, respectively). Conclusions This study suggests that HRQOL can offer better indices for outcomes of digital replantation. This shows some specific replantation cohorts have a significantly better quality of life when compared with their specific correlating revision amputation cohort. These findings can be employed to further refine indications and contraindications to replantation and help predict the quality of life outcomes.

Reconstruction Options for Trunk and Extremity Melanoma

Melanoma is a malignant tumor comprised of the pigment-containing cells known as melanocytes. The most proven risk factors for development of the disease are prolonged sun exposure and being fair-skinned (Fitzpatrick type I–II). In 2017, the incidence rate in the United States was 20.2 per 100,000 people, with ~9730 deaths annually. There are four major histopathologic subtypes of melanoma and their relative incidences are: lentigo maligna (10–40%), superficial spreading (30–60%), nodular (15–35%), and acral lentiginous (5–10%). In addition to the histopathologic subtypes, patient age and the total amount of sun exposure also impact the relative incidence of melanoma. Specifically, lentigo maligna is more commonly found in the elderly patient with chronic sun exposure.

Abstract 98: nipple-sparing mastectomy in patients with previous breast surgery: comparative analysis of 123 immediate reconstructions.

results: 104 patients with prior breast surgery (PBS) underwent 123 NSM with immediate reconstruction. The PBS included 105 lumpectomies, 14 breast augmentations, and 4 breast reductions. A group of 222 patients and 462 NSM reconstructions without prior breast surgery (no PBS) served as the control group. The group with PBS were older (49.6yrs vs. 45.4yrs, p<0.001) but had similar BMI and smoking status. PBS reconstructions were more often unilateral, therapeutic, and associated with preoperative radiotherapy (p<0.001 for each). There were similar percentages of single-stage vs. twostage reconstruction between the groups. The most frequent incision for PBS was use or extension of a pre-existing scar while the most frequent incision for no PBS was the inferolateral IMF incision (p<0.001). There was no significant difference in total complications or individual complications of skin necrosis, nipple necrosis, or implant loss in the group with PBS compared to no PBS (p>0.2 for each). There was a trend toward increased risk of infection in the PBS reconstructions (5.69% vs. 2.38%, p=0.059). When stratifying by type of prior breast surgery, the lumpectomy group had a higher number of patients with preoperative radiotherapy (31 vs. 11, p<0.05) and therapeutic mastectomy (76.2% vs. 40.7%, p<0.05). The breast augmentation patients had a higher number of single-stage reconstructions (92.9% vs. 61.5%, p<0.05) but also an increased risk of total complications (35.7% vs. 13.6%, p<0.05) and a trend toward increased mastectomy skin flap necrosis (14.3% vs. 3.90% p=0.112). There was a trend toward infection and implant loss (25.0% vs. 2.16% p=0.091) in patients with breast reduction.

Impact of Surgeon and Surgical Team on Outcomes in Immediate Implant Based Breast Reconstruction

Background Outcome studies of immediate implant based breast reconstruction (IBR) have largely focused on patient factors, while the relative impact of the surgeon as a contributing variable is not known. In particular, when the procedure requires collaboration of both a surgical oncologist and plastic surgeon, the effect of the surgeon team interaction can have significant impact on outcome. This study examines outcomes in IBR and the association with patient characteristics, surgeon, and surgeon team familiarity. Methods A retrospective review of 3,142 consecutive IBR mastectomy procedures at one institution was performed. Infection rate, skin necrosis and local recurrence were measured. Predictors of outcomes were identified by unadjusted logistic regression followed by multivariate logistic regression. Surgeon teams (oncologic plus reconstructive surgeon) were grouped according to number of cases performed together. Results Patient characteristics remain the most important predictors for outcomes in IBR, with odds ratios above that of surgeon variables. We observed significant differences in rate of skin necrosis between surgical oncologists with approximately two-fold difference between surgeons with the highest and lowest rates (see Table 1). Surgeon teams that worked together on less than 150 procedures had higher rates of infection (OR=2.48, p<0.05) (see Table 2). Conclusion Patient characteristics are the most important predictors for surgical outcomes in IBR, but surgeons and surgeon teams are also important variables. High-volume surgeon teams achieve lower rates of infection. This study highlights the need to examine modifiable risk factors associated with optimum IBR outcomes, which include patient and provider characteristics as well as the surgical team treating the patient.