Stephen J. McCulley

Therapeutic mammaplasty for centrally located breast tumors

Background: Central breast tumors are difficult to manage using breast-conserving treatment. Mastectomy has often been cited as the favored option for these tumors, because lumpectomies that remove the nipple-areola complex often result in poor cosmesis. This article describes the use of therapeutic mammaplasty (a term used to describe breast reduction techniques utilized to treat breast cancer) for centrally sited breast tumors. Methods: The techniques can be broadly divided into two categories: (1) wedge excision, involving wedge excision and a form of wedge closure, and (2) advancement flaps with nipple reconstruction. Results: These techniques were used in 11 patients. Excision margins were complete in all cases except one, due to extensive ductal carcinoma in situ. There have been no other complications and no cases of recurrence to date. Conclusions: When compared with mastectomy and total reconstruction, therapeutic mammaplasty has cosmetic, functional, and recovery time advantages. The techniques described need further evaluation and long-term follow-up. However, they can be added to the repertoire of techniques already established for breast-conserving surgery.

A prospective assessment of shoulder morbidity and recovery time scales following latissimus dorsi breast reconstruction.

Background: The impact on shoulder function from removal of the latissimus dorsi muscle in breast reconstruction is important because of the common nature of this operation. Informed consent requires us to discuss the impact of surgery and likely recovery times. The literature already supports the absence of long-term effects from this procedure. However, all studies and subsequent reviews are based on retrospective studies, thus making it impossible to assess recovery time scales compared with preoperative values. In this prospective study, the authors set out to define the impact on shoulder function and, importantly, to assess recovery time scales compared with preoperative values. Methods: Shoulder range of motion, strength, function, and pain were assessed prospectively in 22 subjects who had latissimus dorsi muscle flap breast reconstruction. Assessments were carried out preoperatively and then at 6 weeks, 6 months, and 1 year postoperatively using standardized objective assessments. Results: The results demonstrate no significant loss of range of motion, strength, function, or pain at 1 year. However, strength, disability scores, neural glide, and discomfort were still abnormal at 6 months and then normalized at 1 year. It was noted that the extended latissimus dorsi flap tended to have poorer scores and recovery compared with a latissimus dorsi flap and implant. Conclusion: The authors believe this information to be important to the patient, therapist, and surgeon in the assessment of postoperative recovery from this procedure.

A Case-Controlled Study of the Oncologic Safety of Fat Grafting

Background: Currently, there is no clinical evidence of oncologic risk associated with fat grafting, although its safety has been questioned. The authors investigated the risk of relapse associated with fat grafting in women with a history of breast cancer. Methods: Of 328 women with previously treated malignant breast disease who underwent fat grafting at the Nottingham Breast Institute, complete data were available for 211 (invasive carcinoma, n = 184; ductal carcinoma in situ, n = 27). Mean follow-up was 88 months after primary cancer surgery and 32 months after fat grafting. Control subjects were matched 2:1 for date of primary cancer operation (within 2 years), age (within 5 years), type of surgery, tumor histology, estrogen receptor status, and disease-free status by time equivalent to that of fat grafting. Final endpoints were tumor recurrence and death. Outcome results were compared with a systematic review of all patients undergoing fat grafting with adequate follow-up reported in the literature. Results: No significant excess oncologic events were observed in patients who had fat grafting compared to controls with regard to local (0.95 percent versus 1.90 percent; p = 0.33), regional (0.95 percent versus 0 percent; p = 0.16), and distant recurrences (3.32 percent versus 2.61 percent; p = 0.65). A systematic review identified case series with a total of 1573 women who had fat grafting after primary oncologic breast surgery. The locoregional relapse rate for these patients was 2.92 percent (0.95 percent per year). Conclusion: This study has found no evidence of increased oncologic risk associated with fat grafting in women previously treated for breast cancer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Therapeutic mammaplasty: Therapeutic Mammaplasty

Therapeutic mammaplasty is a term for the oncoplastic application of breast reduction and mastopexy techniques to treat selected breast tumours by breast conserving surgery (BCS). It has the potential to increase the indications for BCS as well as achieve more acceptable aesthetic results from it in suitable women. Now an established technique in the range of oncoplastic options for women with breast cancer, it finds common application and is associated with good oncological and quality of life outcomes. J. Surg. Oncol. 2014 110:90–95.

Effect of obesity on outcomes of free autologous breast reconstruction: A meta‐analysis

The prevalence of obesity is rising in Western society. The aim of this meta‐analysis was to evaluate the available evidence regarding the effect of obesity on outcomes of free autologous breast reconstruction.Background The prevalence of obesity is rising in Western society. The aim of this meta-analysis was to evaluate the available evidence regarding the effect of obesity on outcomes of free autologous breast reconstruction. Methods Pubmed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov were searched. Obesity was defined as a BMI ≥ 30. Comparable data from observational studies was combined for pooled analysis and quality assessment of observational studies was performed. Results Fourteen studies met the inclusion criteria (n = 6,043 patients). Pooled data analysis demonstrated significantly higher prevalences of overall complications, recipient site complications overall, donor site complications overall, donors site wound infection, donor site seroma, abdominal bulge/hernia, mastectomy skin flap necrosis, recipient site delayed wound healing, and partial flap failure, in obese (BMI ≥ 30) compared with nonobese (BMI < 30) patients. A BMI of 40 was identified as a threshold at which the prevalence of complications became prohibitively high. No randomized-controlled trials were found and all studies had methodological weaknesses. Conclusions Complications in obese patients following free autologous breast reconstruction were higher than in their nonobese counterparts; however the majority of these complications were reported in the studies as being minor. Until better evidence is available this information will help when counseling patients.

Transverse Upper Gracilis (TUG) flap for volume replacement in breast conserving surgery for medial breast tumours in small to medium sized breasts

Excision of medial sited breast tumours in small breasted patients can result in poor cosmetic outcomes, making this a difficult group of patients to manage. Traditional oncoplastic volume replacement techniques available to treat this area of the breast are limited and usually require disruption of the remaining breast to allow access for pedicled flaps. The alternative is mastectomy and total breast reconstruction. The use of a small volume free Transverse upper Gracilis (TUG) flap allows like for like replacement for these defects. Excellent cosmetic results are achievable with minimal breast and donor site morbidity. This initial experience of small volume TUG flaps used in four patients is presented to support the feasibility and assess early outcomes of this technique in the management of this niche group of patients.

short-scar Breast Reduction: Why All the Fuss?

The breast can be considered conceptually as a cone. This article compares and contrasts short‐scar breast reduction techniques with inverted T techniques using the cone model. Four issues are examined—the base of the breast, breast projection, the inframammary fold, and the pedicle. The short‐scar techniques focus on reshaping the breast parenchyma, and skin redraping occurs secondarily. Application of this model suggests that these techniques have the advantage of better projection and greater longevity. These techniques seldom give a square shape and are better at dealing with upper pole deficiency. However, the ability of the skin to redrape is the limiting factor; hence, results are less predictable with large‐volume breast reductions. The emphasis of this article is on increasing the understanding of the mechanics of breast reduction. It is this factor that will enable appropriate selection of a particular technique. (Plast. Reconstr. Surg. 107: 965, 2001.)

Lateral thoracic artery perforator (LTAP) flap in partial breast reconstruction.

BACKGROUND Partial breast reconstruction using pedicled perforator flaps from the thoracodorsal (TDAP) and lateral intercostal arteries (LICAP) is well described. The article introduces the lateral thoracic artery perforator (LTAP) flap as an additional valuable option from the lateral chest wall and reports clinical experience and outcomes. METHODS The anatomy of the LTAP flap is reviewed and the results of a consecutive series are reported. RESULTS In a series of 75 consecutive cases of lateral chest wall perforator flaps used for reconstruction of partial breast defects, 12 (17%) were raised as pure LTAP flaps, and a further 19 (27%) as combined LTAP/LICAP flaps. The LTAP was therefore used in 44% of flaps overall. One LTAP flap (delayed case) had early venous compromise that settled spontaneously. DISCUSSION The LTAP flap is a reliable option for partial breast reconstruction from the lateral chest wall, particularly in the immediate setting. It allows comparable flap size to be harvested compared to LICAP flaps. The LTAP flap can be raised on its own pedicle allowing greater mobilization or it can be incorporated into the more commonly used LICAP flap to augment perfusion.

Qualitative mammographic findings and outcomes of surveillance mammography after partial breast reconstruction with an autologous flap

This study describes the qualitative mammographic features after partial breast reconstruction with an autologous flap, and evaluates the diagnostic accuracy and recall rates of surveillance mammography after volume replacement in breast conserving surgery.Background This study describes the qualitative mammographic features after partial breast reconstruction with an autologous flap, and evaluates the diagnostic accuracy and recall rates of surveillance mammography after volume replacement in breast conserving surgery. Methods Patients who had autologous partial breast reconstruction (N = 102) after breast-conserving surgery using either the myocutaneous latissimus dorsi mini-flap (N = 39) or fasciocutaneous chest wall perforator flap (N = 63) were reviewed. Mammograms done at one-year post surgery were analysed for characteristic qualitative features. All surveillance mammograms, diagnostic imaging and medical records were retrospectively reviewed. Results Mammograms of partially reconstructed breasts had distinctive features that correlated well with the surgical procedures. Median follow-up was 3 years, range 0–11 years. Of 295 surveillance mammograms, six (2%) resulted in a recall for further imaging and 3 (1%) proceeded to needle biopsy. Diagnostic imaging was performed for 13 (13/102, 12.7%) patients with symptoms, and only one (1/102, 1%) required a diagnostic biopsy. Conclusions A conserved breast with an autologous flap within has characteristic mammographic features that differ from those after standard breast conserving surgery. Surveillance mammography after partial breast reconstruction is accurate, and recall/biopsy rates are low. Diagnostic breast ultrasound examination is effective evaluation for the symptomatic patient. J. Surg. Oncol. 2015 111:377–381.