Julie E. Park

Optimizing delivery of breast conservation therapy: a multidisciplinary approach to oncoplastic surgery.

BackgroundFor patients with small breasts relative to tumor size and for those with tumors in the central or inferior poles, lumpectomy can be aesthetically devastating. The field of oncoplastic surgery has developed to offset the aesthetic pitfalls of breast conservation. Questions remain regarding oncologic safety, potential complications, and patient selection. In this study, we report our institutional, multidisciplinary experience with oncoplastic surgery. MethodsA retrospective review was performed including all patients at our institution undergoing oncoplastic breast surgery between 2003 and September 2009 at an academic medical center. Mean follow-up period was 38 months. All patients were referred by the institutional multidisciplinary breast team. ResultsForty-five female patients underwent 46 oncoplastic breast reconstructions. Immediate reconstruction was performed in 21 patients, early (within 9 to 73 days of final tumor resection) in 18, and delayed (following completion of radiation) in 6. Three patients (14%) who underwent immediate oncoplastic reconstruction had positive margins on final pathology and proceeded to completion mastectomy. No local cancer recurrence was seen. Two patients developed distant metastatic disease. Twelve complications occurred in 11 patients; by group, 2 (10%) in immediate, 7 (39%) in delayed-immediate group, and 2 (33%) in delayed. Immediate oncoplastic reconstruction, performed as a single-stage procedure, inversely correlated with complication risk (P = 0.059). No other risk factor correlated with complications. ConclusionsOur review suggests this multidisciplinary approach to oncoplastic surgery is safe. Interestingly, women undergoing immediate oncoplastic reconstruction trended toward a lower rate of complications. The benefit of immediate reconstruction must be balanced by risk of positive tumor margin and subsequent necessity for completion mastectomy. This risk–benefit balance may be best delivered by a multidisciplinary team focused on all aspects of breast cancer care.

TUGs into VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option.

Background: The best secondary option for autologous breast reconstruction remains controversial. Limitations of the gracilis myocutaneous flap, including volume, skin paddle reliability, and donor morbidity, have been addressed by several modifications, hereby expanding its role in the decision tree for autologous breast reconstruction. This report documents the authors’ experience with gracilis flap breast reconstruction. Methods: This is a retrospective case series of a prospectively maintained database of patients undergoing breast reconstruction with the free gracilis myocutaneous flap, including the transverse upper gracilis, vertical upper gracilis, and bilateral stacked vertical upper gracilis. Results: Twenty-two patients received gracilis myocutaneous flaps. Fourteen (63.6 percent) had previous attempted breast reconstructions. Indications for gracilis donor site were previous abdominoplasty/abdominal flap (n = 15, 68 percent), insufficient abdominal tissue (n = 6, 27 percent), and patient preference (n = 1, 5 percent). Six patients underwent bilateral reconstruction, and five underwent unilateral reconstruction with bilateral stacked gracilis flaps. The skin paddle was transverse in four flaps (12 percent) and vertical in 29 (88 percent). There was one flap loss (3 percent); there were two occurrences of fat necrosis (6 percent). There were two minor donor site dehiscences (6 percent), one infection (3 percent), and one seroma (3 percent). Conclusions: The free gracilis flap is a versatile option for patients undergoing breast reconstruction, particularly when the abdominal donor site is unavailable. The vertical pattern is the authors’ preferred technique, as it avoids some of the problems associated with transverse patterns. Stacked flaps further expand the utility of this technique, which the authors regard as the best secondary option for autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cancer Risk after Fat Transfer: A Multicenter Case-Cohort Study.

Background: Fat transfer is an increasingly popular method for refining postmastectomy breast reconstructions. However, concern persists that fat transfer may promote disease recurrence. Adipocytes are derived from adipose-derived stem cells and express adipocytokines that can facilitate active breast cancer cells in laboratory models. The authors sought to evaluate the association between fat transfer to the reconstructed breast and cancer recurrence in patients diagnosed with local or regional invasive breast cancers. Methods: A multicenter, case-cohort study was performed. Eligible patients from four centers (Memorial Sloan Kettering, M. D. Anderson Cancer Center, Alvin J. Siteman Cancer Center, and the University of Chicago) were identified by each site’s institutional tumor registry or cancer data warehouse. Eligibility criteria were as follows: mastectomy with immediate breast reconstruction between 2006 and 2011, age older than 21 years, female sex, and incident diagnosis of invasive ductal carcinoma (stage I, II, or III). Cases consisted of all recurrences during the study period, and controls consisted of a 30 percent random sample of the study population. Cox proportional hazards regression was used to evaluate for association between fat transfer and time to recurrence in bivariate and multivariate models. Results: The time to disease recurrence unadjusted hazard ratio for fat transfer was 0.99 (95 percent CI, 0.56 to 1.7). After adjustment for age, body mass index, stage, HER2/Neu receptor status, and estrogen receptor status, the hazard ratio was 0.97 (95 percent CI, 0.54 to 1.8). Conclusion: In this population of breast cancer patients who had mastectomy with immediate reconstruction, fat transfer was not associated with a higher risk of cancer recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Reconstruction with SIEA Flaps: A Single-Institution Experience with 145 Free Flaps.

Background: Refinements in microsurgical breast reconstruction have refined superficial inferior epigastric artery (SIEA) and superficial circumflex iliac artery (SCIA) flaps, yet technical difficulties and varied success rates limit widespread acceptance. The authors present the outcomes of their experience with 145 consecutive SIEA/SCIA flaps and suggest technical tips to improve success with this important flap. Methods: An institutional review board–approved retrospective chart review of all SIEA/SCIA free flaps performed by the senior authors between January 1, 2006, and February 6, 2014, was conducted. Data on patient demographics, flap characteristics, and complications were collected. Results: There were 145 flaps performed in 119 patients. Arterial donor and recipient mismatch occurred in 55 instances (38 percent). In these cases, 48 arteries (87 percent) were spatulated and seven (13 percent) were back-cut to improve size concordance. Nine flaps required operative return for flap viability concerns. Five were arterial, three were venous, and one flap had concomitant arterial and venous thrombosis. Total flap loss rate attributable to thrombotic events was 4.8 percent. No flaps with arterial thrombosis on reoperation were salvageable. Furthermore, 80 percent had arterial revisions at initial operation. No patients had an abdominal bulge or hernia, and the fat necrosis rate was 10.3 percent. Conclusions: SIEA/SCIA breast reconstruction can be reliably performed; however, flaps exhibiting postoperative arterial thrombosis with revision at initial surgery are unlikely salvageable on reoperation. Spatulation did not correlate with an increased thrombosis rate; in fact, the authors advocate for donor artery manipulation to manage size mismatch. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pre‐mastectomy Sentinel Lymph Node Biopsy: A Strategy to Enhance Outcomes in Immediate Breast Reconstruction

The pre‐mastectomy sentinel lymph node biopsy (PM‐SLNB) is a technique that provides knowledge regarding nodal status prior to mastectomy. Because radiation exposure is associated with poor outcomes in breast reconstruction and reconstructed breasts can interfere with the planning and delivery of radiation therapy (RT), information regarding nodal status has important implications for patients who desire immediate breast reconstruction. This study explores the safety and utility of PM‐SLNB as part of the treatment strategy for breast cancer patients desiring immediate reconstruction. We reviewed the charts of adult patients (≥18 years old) who underwent PM‐SLNB from January 2004 to January 2011 at our institution. PM‐SLNB was offered to patients with stage I or IIa, clinically and/or radiographically node‐negative breast cancer who desired immediate breast reconstruction following mastectomy. PM‐SLNB was also offered to patients with ductal carcinoma in situ if features concerning for invasive carcinoma were present. Ninety‐one patients underwent PM‐SLNB of 94 axillae. PM‐SLNB was positive in 25.5% of breasts (n = 24). Nineteen node‐positive patients (79.2%) have undergone or planning to undergo delayed reconstruction at our institution. Seventeen of these 19 node‐positive patients (89.5%) have received adjuvant RT. Two patients (10.5%) elected against RT despite our recommendation for it. No biopsy‐positive patient underwent immediate reconstruction or suffered a radiation‐induced complication with their breast reconstruction. There were two minor complications associated with PM‐SLNB, both in node‐negative patients. This study demonstrates the utility of PM‐SLNB in providing information regarding nodal status, and therefore the need for adjuvant RT, prior to mastectomy. This knowledge can be used to appropriately counsel patients regarding optimal timing of breast reconstruction.

Advances and Innovations in Microsurgery

Learning Objectives: After reading this article, the participant should be able to: 1. summarize the evolution of perforator, chimeric, and free style flaps; 2. define and give examples of supermicrosurgery as well as understand its application in treatment of lymphedema; and 3. appreciate the development and advancements of composite tissue allotransplantation. Summary: Although microsurgery may seem like a highly specialized niche within plastic surgery, it is more than just a discipline that focuses on small anastomoses. It is a tool and a way of thinking that allows us to embody the true tenets of plastic surgery, as quoted by Tagliocozzi. What began as a challenge of returning amputated tissue to the body and achieving wound closure has evolved into a refinement of technique and change in philosophy that empowers the plastic surgeon to work creatively to “restore, rebuild, and make whole.”

Parental leave policies in graduate medical education: A systematic review

BACKGROUND A thorough understanding of attitudes toward and program policies for parenthood in graduate medical education (GME) is essential for establishing fair and achievable parental leave policies and fostering a culture of support for trainees during GME. METHODS A systematic review of the literature was completed. Non-cohort studies, studies completed or published outside of the United States, and studies not published in English were excluded. Studies that addressed the existence of parental leave policies in GME were identified and were the focus of this study. RESULTS Twenty-eight studies addressed the topic of the existence of formal parental leave policies in GME, which was found to vary across time and ranged between 22 and 90%. Support for such policies persisted across time. CONCLUSIONS Attention to formal leave policies in GME has traditionally been lacking, but may be increasing. Negative attitudes towards parenthood in GME persist. Active awareness of the challenges faced by parent-trainees combined with formal parental leave policy implementation is important in supporting parenthood in GME.

A Simple, Safe Technique for Thorough Seroma Evacuation in the Outpatient Setting

Summary: Seroma formation, a common postoperative complication in reconstructive cases, can lead to capsular contracture and increased office visits and expenses. The authors present a safe, novel technique for ensuring the thorough removal of serous fluid in the outpatient setting. By relying on access with an angiocatheter, potential injury to permanent implants is minimized. The use of low continuous wall suction obviates the need of manual suction via multiple syringes and offers a rapid and thorough evacuation of all types of seromas.

The Role of the Plastic Surgeon in Sentinel Lymph Node Biopsy of Internal Mammary Nodes

The presence of lymph node metastasis is the single most important prognostic factor in the staging of breast cancer. While the majority of lymphatic drainage of the breast is to the axillary nodes, the most common extra-axillary site of lymph drainage is the internal mammary chain (IMC). The primary method for assessing the tumor status of these nodes is a sentinel lymph node (SLN) biopsy, which allows a surgeon to sample only the primary drainage sites of the tumor rather than performing a complete dissection of the nodal basin. Currently SLN biopsy is routinely used to determine axillary lymph node status in clinically node negative patients with breast cancer, however it is not commonly used to sample IMC SLNs [1]. Although there is much literature arguing for and against routine IMC SLNs, none specifically describe techniques for biopsy of these nodes, particularly when the nodes are more difficult to access. We believe that IMC SLN biopsies can alter the course of treatment and that the plastic surgeon, who has experience working in that difficult-to-navigate region of the thorax, is ideally equipped to perform them. A 47-year-old woman with a history of stage II (T2N0), estrogen receptor (ER) positive, progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER-2)/neu amplified left breast invasive ductal carcinoma in the lower inner quadrant presented with a new 4.2 cm magnetic resonance imaging-demonstrated mass in the lower outer quadrant. Her first cancer was treated with lumpectomy, axillary SLN biopsy, adjuvant chemotherapy consisting of adriamycin/cyclophosphamide followed by paclitaxel and 1 year of herceptin, and 60.8 Gy of adjuvant radiation therapy. After treatment she remained on tamoxifen. A core biopsy of the new mass showed triple negative invasive ductal carcinoma. She was treated with neoadjuvant chemotherapy consisting of four cycles of gemcitabine and carboplatin with a minimal response. Three weeks before her mastectomy lymphoscintigraphy showed drainage to the internal mammary nodal basin, and biopsy was indicated to determine the need for adjuvant radiation therapy. Plastic surgery was consulted to perform the procedure. One day prior to surgery a dose of 01.05 mCi of 99m-technetium labeled sulfur colloid was given in 4 intradermal injections around the areola. In one hour 3 SLNs were visualized in the IMC (Fig. 1) using a dual head gamma camera (Brightview, Phillips, Andover, MA, USA). The overlying skin was marked. Fig. 1 Left breast lymphoscintigraphy: anterior view. RT, right; LT, left. After induction of general anesthesia, 4 mL of methylene blue dye was injected subcutaneously and into the breast tissue in the retroareolar region, and the breast was massaged for ten minutes to promote drainage. A gamma ray detection probe (Navigator, RMD Instruments, Watertown MA, USA) revealed increased radioactivity in the medial superior left breast, a few centimeters lateral to the sternal border. Following the raising of skin flaps and resection of the breast tissue medially by the breast surgeon, the plastic surgeon (J.E.P.) performed the biopsy. The internal mammary vessels and adjacent lymph nodes were exposed by splitting the longitudinal fibers of the pectoralis major muscle. The anterior perichondrium of the second costal cartilage was scored and elevated off of the cartilaginous rib, and the rib was incised both laterally and medially using a 10-blade. To protect the underlying pleura, a Doyen was used to separate the posterior perichondrium from the underlying rib, which was then resected. The internal mammary vessels and nodes were exposed by carefully removing the posterior perichondrium. The gamma probe identified a single SLN. Lymph channels and nearby vessels were ligated using 4-0 silk ties, small clips and bipolar cautery, and the node was excised. There was no evidence of pleural violation. The posterior perichondrium was laid back over the vessels, the split in the pectoralis was repaired, and the breast surgeon completed the mastectomy. The pathology report showed no involvement of the IMC SLN, staging the tumor as T2N0M0, and the decision was made to forgo additional radiation therapy. There were no perioperative complications. Two months later she underwent prophylactic right mastectomy and bilateral reconstruction. Debate exists over whether routine IMC SLN biopsy is appropriate. Studies have shown that complete IMC node dissection showed no improvement in survival; however, these studies primarily contained patients with tumors in the lateral quadrants, which are less likely to drain to the IMC, and the studies were underpowered with regards to patients with tumor drainage to the parasternal region [2]. Physicians opposed to routine IMC SLN biopsy argue that the only significant treatment change from identifying a positive IMC node is in adjuvant locoregional radiation therapy, which has not been proven to significantly alter survival and can lead to significant morbidities such as radiation pneumonitis and cardiac compromise [3]. However, in the case of a positive IMC node, loco-regional radiation therapy does increase survival rates [4], and if it is negative, as it was in our patient, the side effects of radiation can be avoided. Additionally several physicians consider a positive IMC node an indication for adjuvant systemic therapy [1,4]. Studies performed by breast surgeons have reported that they never resect a rib to access IMC nodes due to increased morbidity [1,5]. Plastic surgeons perform this procedure frequently when preparing recipient vessels during breast reconstruction, and can comfortably perform the same procedure to access the IMC SLN immediately following a mastectomy. In the more difficult case where there is not a mastectomy, the use of the vertical mastopexy incision can allow access to the rib cartilage and the IMC without creating a parasternal incision, which would cause an unsightly scar. For these reasons, a plastic surgeon performs SLNB of IMC nodes at our institution. This case demonstrates the safety and efficacy of IMC SLN node biopsy when done by the reconstructive plastic surgeon, and how knowledge of IMC nodal status can influence the course of treatment. In a multidisciplinary approach to the treatment of breast cancer, the plastic surgeon is responsible for reconstruction but can also be instrumental in determining staging and treatment. IMC SLN biopsy is an important technique in the evaluation of early breast cancer in select patients, and we believe that the plastic surgeon has the ideal skill set to perform it safely and effectively.

Resident Leave in Plastic Surgery Training

In 2009, the minimum requirement for dedicated plastic surgical training increased from 2 to 3 years. Increasingly, programs are converting to an integrated model, where plastic surgery training starts in internship and typically lasts for 6 years. The average age of matriculating medical students is 24 years (women) and 25 years (men).1 Thus, estimating 4 years of medical school and 6 years of residency, the average program will train residents from the ages of 28 to 29 through 34 (integrated 6 years) to 36 (independent 5 + 3 years), excluding additional research time. During this extended period of the lives of residents, it is only natural that life events continue to occur. These include marriage, parenthood, becoming sick or disabled, or experiencing personal hardships. At times, these events necessitate residents taking leave of absence from training.2 Thus, the issue of resident leave in plastic surgery training must be considered in more depth. The ages of 28 to 36 years represent a prime period in residents’ lives in which they may become parents. Therefore, it is important to have an open discussion on the attitudes, environment, and support for parental leave. Female residents, in particular, often delay childbearing,3 thus increasing the risk of infertility and pregnancy complications. As women in plastic surgery residencies have increased from 12.5% (1989) to 37% (2015),4 this affects a significant number of our plastic surgical residents. Since the early 1990s, there have been 13 publications on the topic of “leave in plastic surgery residency”, including 2 prospective cohorts (1995 and 2015),2,5 1 editorial, and 10 letters to the editor. Forty-six percent of women had their first child during residency,5 and 73% of programs had experience with either a resident or spouse of a resident pregnancy over a 5-year period.2 Seventy-five percent of female residents worked up to the day of delivery,5 88% took less than 6 days off after delivery in 1995,5 and only 22 women of 131 residents took more than 3 weeks in 2015; 11 of whom made up the time.2 Specific logistics of parental leave are left to individual plastic surgery residency programs, provided that they abide by the rules of governing bodies within graduate medical education, such as the Accreditation Council for Graduate Medical Education, which includes following appropriate federal laws, such as the Family and Medical Leave Act. The American Board of Plastic Surgery (ABPS) requires “at least 48 weeks of full-time training experience per year” for board eligibility. The 48 weeks may be averaged over the training years, allowing for some flexibility, but limits “extra” time for leaves of absence. In the current era of competency-based training coupled with increased training length, is the 48-week/year requirement still appropriate? The American Council of Academic Plastic Surgeons has created a resident leave task force to address these issues in depth and to develop recommendations that will be presented to the ABPS to be considered for a universal resident leave policy.