Alexandra M. Hart

The use of reduction mammaplasty with breast conservation therapy: an analysis of timing and outcomes.

Background: Oncoplastic reduction mammaplasty is often used to prevent or correct breast conservation therapy deformities. The purpose of this review was to evaluate surgical outcomes, patient satisfaction, and aesthetic outcomes of this procedure when performed before or after radiation therapy. Methods: Breast cancer patients treated with breast conservation therapy and reduction mammaplasty between 2005 and 2012 were divided into immediate reconstruction, delayed immediate reconstruction, and delayed reconstruction. Greater than 6-month follow-up was required for inclusion. Patient demographics and clinical outcomes, including complications, patient satisfaction, and aesthetic result, were queried. Patient satisfaction was determined using the BREAST-Q survey. Postoperative photographs were used to rate aesthetic outcomes blinded to the timing of the procedure. Results: Patients in the immediate reconstruction group had fewer complications (immediate reconstruction, 20.5 percent; delayed immediate reconstruction, 33.3 percent; delayed reconstruction, 60.0 percent; p < 0.001) and asymmetry (immediate reconstruction, 8.5 percent; delayed immediate reconstruction, 44.4 percent; delayed reconstruction, 24.0 percent; p < 0.001), and required fewer procedures to complete the reconstruction (immediate reconstruction, 1.2; delayed immediate reconstruction, 2.4; delayed reconstruction, 2.2; p < 0.001). Delayed reconstruction resulted in higher complication and fat necrosis rates (immediate reconstruction, 0.9 percent; delayed immediate reconstruction, 0.0 percent; delayed reconstruction, 8.0 percent; p = 0.047). Although patient satisfaction and aesthetic outcomes were better in the immediate reconstruction group, this difference was not statistically significant. Conclusions: Oncoplastic reduction techniques performed before radiation therapy result in fewer complications. Good patient satisfaction and aesthetic outcomes can be achieved when reduction is performed before or after radiation therapy, but patient selection and education are important. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Oncoplastic Reduction Approach to Breast Conservation Therapy: Benefits for Margin Control

BACKGROUND Reduction mammaplasty during lumpectomy allows more generous resection and minimizes potential for poor cosmesis as compared with breast conservation therapy alone. OBJECTIVES The authors assessed the benefits of oncoplastic reduction for margin status in patients with breast cancer by conducting a retrospective review of cases of tumor resection alone vs tumor resection with oncoplastic reduction. METHODS Patients with breast cancer who underwent lumpectomy performed by a single oncologic surgeon between 2009 and 2013 were included. Patients were stratified into 2 groups based on surgical procedure: tumor resection with oncoplastic reduction (group 1) vs tumor resection alone (group 2). Patient demographics including risk factors, diagnosis, cancer stage, and procedure type were recorded. Tumor size, specimen weight, width of narrowest margin, and receptor status were determined. Outcome variables included margin positivity (≤1 mm), need for re-excision, and conversion to completion mastectomy. RESULTS A total of 222 breasts from 207 patients were included in the study: 83 in group 1 and 139 in group 2. The patients in group 1 had a lower incidence of positive margins and wider free surgical margins, required re-excision less often, and went on to completion mastectomy less often. Patients in group 1 were younger and had cancer that was more advanced. When controlling for these variables on multivariate regression analysis, the oncoplastic technique was independently associated with fewer positive margins and fewer instances of re-excision. CONCLUSIONS The oncoplastic reduction technique achieves wider free margins and less often necessitates re-excision or subsequent mastectomy. The long-term oncologic effect of this approach deserves further study. LEVEL OF EVIDENCE 4.

The Effect of Bmi on Outcomes Following Complex Abdominal Wall Reconstructions

BackgroundThe management of complex abdominal wall defects continues to be a challenging process secondary to the high potential for wound healing issues and ventral hernia recurrences. Body mass index (BMI) is a well-known risk factor when it comes to complications. We hypothesize that higher BMIs result in higher rates of postoperative complications in complex abdominal wall reconstructions (CAWRs). MethodsWe retrospectively reviewed all patients who underwent CAWR at Emory University Hospital over a 12-year period. Patients were divided into 4 cohorts based on BMI (15–24.9, 25–29.9, 30–34.9, and ≥35 kg/m2). Complication rates among the 4 groups were evaluated as the primary outcome using Pearson &khgr;2 analysis. Further analysis was done on specific complications including mesh exposure, skin necrosis, delayed healing, rate of fistula formation, seroma, hematoma, infection, rate of recurrence, and rate of reoperation. ResultsWe included 313 patients with a mean follow-up of 15.6 months. The rate of overall complications demonstrated a nonsignificant increase with BMI of 15 to 24.9, 25 to 29.9, 30 to 34.9, and 35 kg/m2 or greater (31.7%, 35.0%, 47.6%, and 48.3%; P = 0.079, respectively). The rate of skin necrosis was significantly increased in the higher BMI groups (1.7%, 1.3%, 9.5%, and 13.5%; P = 0.004). The rate of ventral hernia recurrence was significantly increased in the higher BMI groups (8.3%, 12.5%, 29.8%, and 27.0%; P = 0.002). Rates of reoperation were also statistically increased in the higher BMI groups (25.0%, 22.5%, 41.7%, and 34.8%; P = 0.035). Rates of mesh exposure, delayed healing, fistula formation, seroma, hematoma, and infection were not statistically significant among the 4 BMI groups. ConclusionsPatients undergoing CAWR with BMIs greater than 30 kg/m2 have significantly higher rates of skin necrosis, hernia recurrence, and reoperation compared with subgroups of lower BMI. Rates of overall complications among all BMI groups are similar, although trended up with BMI. Surgeons should weight the risks and benefits of CAWR in patients with higher BMIs to reduce specific postoperative complications.

The Psychosexual Impact of Partial and Total Breast Reconstruction: A Prospective One-Year Longitudinal Study.

BackgroundThis prospective trial sought to explore patients’ satisfaction and expectations for surgery in the areas of sexuality and body image and to evaluate outcomes pertaining to sexual well-being after total and partial breast reconstruction (BR). MethodsPatients who underwent mastectomy and immediate total BR (group 1; n = 60) or lumpectomy and reduction mammoplasty (group 2; n = 10) completed a questionnaire preoperatively and 1 year postoperatively to assess their satisfaction with their sex life and body image, perceptions of breasts as a source of sexuality, and expectations of surgery in these areas. Surveys were scored on a 5-point Likert scale, with 5 indicating strongly agree. Change scores were evaluated in the 2 groups (P = 0.05). ResultsIn group 1, satisfaction with sex life and body image was unchanged. Pursuit of sexual attractiveness (from 3.78 to 3.31, P = 0.02) and an improved body image (from 3.89 to 3.33, P < 0.01) were cited as expectations for surgery but were achieved less often. When stratified by different types of reconstruction, there were no discernible differences in responses. In group 2, the patients reported an unexpected increase in their partner’s perception of them as womanly (from 1.33 to 2.50, P = 0.01) and greater gains in the ability to wear sexually provocative clothing (from 1.78 to 3.11, P < 0.01).Preoperative expectations for improved body image were more often met in group 2 than group 1 (from 3.60 to 4.00 vs from 3.89 to 3.33, P = 0.02). Group 2 experienced greater improvement in body image satisfaction (from 2.80 to 3.80 vs from 3.37 to 3.44, P = 0.03). ConclusionsOverall satisfaction with sex life and body image was preserved for both groups; however, the oncoplastic approach achieved significantly larger gains in body image perception.

A Complication Analysis of 2 Acellular Dermal Matrices in Prosthetic-based Breast Reconstruction.

Background: Acellular dermal matrices (ADM) are now routine in postmastectomy prosthetic-based breast reconstruction. The goal of the current study was to compare the complications of 2 ADM products—AlloDerm and Cortiva. Methods: A retrospective analysis of prosthetic-based breast reconstruction in Atlanta, Ga., over 5 years. Inclusion criteria were the use of the ADM types (AlloDerm or Cortiva) and use of a tissue expander or implant. Statistical analysis compared group demographics, risk factors, and early complications. Results: Of the 298 breast reconstructions, 174 (58.4%) used AlloDerm and 124 (41.6%) used Cortiva. There was no difference in overall complication frequency (16 AlloDerm and 18 Cortiva; P = 0.195). Within specific categories, there was a difference in mastectomy skin flap necrosis, but, based on further regression analysis, this was attributable to differences in body mass index (P = 0.036). Furthermore, there were no differences in the rates of infection (6 AlloDerm and 5 Cortiva; P = 1.0), seroma/hematoma (9 AlloDerm and 7 Cortiva; P = 1.0), or drain duration (13.2 day AlloDerm and 14.2 day Cortiva, P = 0.2). By using a general estimating equation for binomial logistical regression, it was found that only current tobacco use (P = 0.033) was a significant predictor for a complication. Trending predictors were body mass index (P = 0.074) and age (P = 0.093). The type of matrix was not a significant predictor for any of the recorded complication (P = 0.160). Conclusions: Although AlloDerm is well established, we have shown that Cortiva has an equivalent complication frequency. Future work will focus on long-term outcome measures and histological evaluation of vascularization and integration.

The Impact of Diabetes Mellitus on Wound Healing in Breast Reconstruction

Background Although diabetes mellitus (DM) is a known risk factor for surgical complications in general, there is little published evidence to establish such an effect among patients undergoing breast reconstruction (BR). The purpose of this study was to assess the impact of DM on complications in patients undergoing postmastectomy BR. Methods Patients who underwent BR at our institution from November 2002 to November 2012 were identified. Clinical and demographic data of patients with type 1 or type 2 DM were reviewed. Complications occurring within 60 days of surgery were compared between diabetic and nondiabetic patients for both autologous and nonautologous reconstruction types. Results A total of 1371 BR were performed in 1035 patients. There were 877 (64.0%) autologous reconstructions and 494 (36.0%) implant-based reconstructions. Patients with DM (n = 64) had significantly higher preoperative blood glucose levels (137.5 vs 100.1, P < 0.05). Postoperatively, DM patients reconstructed with implants had a significantly higher incidence of delayed wound healing (22.2% vs 9.7%; P = 0.04). This was not observed in patients with DM reconstructed with autologous tissue (7.4% vs 6.6%; P = 0.70). Diabetic patients had a significantly higher incidence of hypertension and were older than nondiabetic patients. To control for these variables and other potential confounders, multiple logistic regression analysis was performed. Again, diabetic patients had a significantly higher incidence of delayed wound healing following implant-based reconstruction (odds ratio, 2.52, 95% confidence interval = 1.2–6.2) but not autologous reconstruction (odds ratio, 0.97; 95% confidence interval = 0.2–4.6). Conclusions Diabetes heightens the risk of wound healing complications among patients undergoing implant-based reconstruction.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Summary: The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Incidence of Methicillin-Resistant Staphylococcus aureus (MRSA) Carrier Status in Patients Undergoing Post-Mastectomy Breast Reconstruction

Background The incidence of methicillin-resistant Staphylococcus aureus (MRSA) carriers and infections continues to rise. Some specialties have demonstrated a reduction in infection through appropriate screening and treatment. Objectives We sought to investigate the incidence of preoperative colonization, postoperative conversion, and whether this had any impact on outcomes in patients undergoing post-mastectomy breast reconstruction (BR). Methods This is a prospective study of a series of 122 BR patients from a single surgeon from May 2013 to March 2015. Nasal swabs were obtained at preoperative and postoperative clinic visits. The incidence of preoperative and postoperative colonization, demographic, and clinical variables were analyzed and compared to complication rates within 90 days of surgery. Results The incidence of MRSA colonization was 3.3% (n = 4) preoperatively and 4.1% (n = 5) postoperatively. One patient was positive at both time points, and 4 patients converted postoperatively. Preoperative or postoperative colonization with MRSA was not associated with any specific patient demographics. Hospital length of stay tended to be longer in patients colonized both preoperatively (2.8 days vs 1.6 days, P = .075) and postoperatively (2.8 days vs 1.8 days, P = .072). Postoperative colonization trended toward an increased incidence of any complication (80.0% vs 35.7%, P = .068) and was significantly associated with delayed wound healing (40.0% vs 4.8%, P = .035). Having a minor complication (P = .073) and implant exposure (P = .056) tended to be associated with postoperative carriers. Conclusions The incidence of MRSA in breast reconstruction patients is relatively low, yet complications rates are higher in those patients. Multicenter randomized trials should be conducted to determine if there is a role for preoperative screening and treatment of MRSA carriers. Level of Evidence 2 Risk

Patient-Reported Quality of Life After Breast Reconstruction: A One-Year Longitudinal Study Using the WHO-QOL Survey.

BackgroundPatient-reported quality of life (QOL) is an important measure of the impact that breast reconstruction has on postmastectomy patients. This study seeks to describe psychosocial outcomes after breast reconstruction and to identify factors that influence them. MethodsAll patients who underwent immediate postmastectomy reconstruction by the senior author between 2009 and 2011 were offered participation in this study. Patients completed the World Health Organization QOL-BREF questionnaire preoperatively and 1-year postoperatively. Change scores were compared across reconstructive techniques, as well as across various demographic and clinical variables. ResultsOne hundred twenty-nine women completed the preoperative questionnaire, and 60 patients completed the follow-up questionnaire at 1 year (response rate, 46.5%). Compared to the preoperative baseline, overall QOL was unchanged, general satisfaction with health improved significantly, and QOL in physical, psychological, social, and environmental domains decreased (P < 0.05 for all but social domains). On bivariate analysis, being in a relationship at the time of reconstruction was associated with a decline in overall QOL, as well as the quality of social relationships and environment. Educational level impacted how physical and psychological wellness evolved after surgery. Patients with a higher cancer stage reported a decrease in satisfaction with health at 1 year. Type of reconstruction, development of a complication, and need for additional surgery did not influence any of these outcomes. ConclusionsAt 1-year follow-up from postmastectomy reconstruction, breast cancer survivors report a similar overall QOL, but significant decrements in physical, psychological, and environmental QOL. Satisfaction with health improved. The type of breast reconstruction did not influence any of these outcomes.

Do Medical Students in the Operating Room Affect Patient Care? An Analysis of One Institution’s Experience Over the Past Five Years

BACKGROUND Medical students are active learners in operating rooms during medical school. This observational study seeks to investigate the effect of medical students on operative time and complications. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to operative records for nonemergent, inpatient general surgery cases at our institution from 1 January 2009 to 1 January 2013. Cases were grouped into 13 distinct procedure groups. Hospital records provided information on the presence of medical students. Demographics, comorbidities, intraoperative variables, and postoperative complications were analyzed. RESULTS Overall, 2481 cases were included. Controlling for wound class, procedure group, and surgeon, medical students were associated with an additional 14 minutes of operative time. No association between medical students and postoperative complications was observed. CONCLUSIONS The educational benefits gained by the presence of medical students do not appear to jeopardize the quality of patient care.