The effect of chemotherapy on the complication rates of implant and free flap breast reconstruction: A Systematic Review

Abstract Purpose This study investigated the impact of chemotherapy on complication rates of implant and free flap breast reconstruction. The effect of timing and dosage of chemotherapy in minimizing the breast reconstruction surgery (BRS) complications were also investigated. Methods PRISMA guidelines were used to search relevant studies published from January 2009 to September 2021. Quality of selected studies were assessed using GRADE assessment and risk of bias was performed using Cochrane Collaboration’s tool and ROBINS-I. Rates of major and minor complications of neoadjuvant systemic therapy (NST) and adjuvant systemic therapy (AST) were compared by t-test using GraphPad Prism v.9.3.0 and P value <0.05 was considered statistically significant. Results A total of 19 studies comprising 49,217 patients were included. The GRADE assessment showed low risk of bias and good quality across studies. Three-hundred and twenty patients had implant reconstruction, 3,172 had flap reconstruction and 46,062 had both flap and implant reconstruction surgery. There was no significant difference in complication rates of patients between flap reconstruction surgery and implants. (P=0.4) In all studies, total complication rates for post-chemotherapy BRS patients was 46.03% compared to 32.49% without chemotherapy (P=0.09). Overall major complications rate was 14.5% (P=0.61) with NST and 21.1% (P=0.69) with AST. Minor complications rate was 28.8% (P=0.97) with NST and 39.5% (P=0.59) with AST. Complication rate of NST was lower than AST, but not statistically significant (P=0.64). No significant correlation was found between timing/duration of chemotherapy and rates of BRS complications (P=0.76). Conclusion No significant difference in BRS complications with and without chemotherapy was established. Despite these results suggesting little difference between NST and AST or chemotherapy in BRS complications, prospective control studies are currently limited, and more are necessary to better inform surgeons and their patients.

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A meta-analysis indicating extra-short implants (≤ 6 mm) as an alternative to longer implants (≥ 8 mm) with bone augmentation

Scientific Reports ◽

10.1038/s41598-021-87507-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Xiaoran Yu ◽

Ruogu Xu ◽

Zhengchuan Zhang ◽

Yang Yang ◽

Feilong Deng

Keyword(s):

Survival Rate ◽

Clinical Outcomes ◽

Meta Analysis ◽

Risk Of Bias ◽

Bone Augmentation ◽

Moderate Quality ◽

Short Implants ◽

Significant Difference ◽

Complications Rate

AbstractExtra-short implants, of which clinical outcomes remain controversial, are becoming a potential option rather than long implants with bone augmentation in atrophic partially or totally edentulous jaws. The aim of this study was to compare the clinical outcomes and complications between extra-short implants (≤ 6 mm) and longer implants (≥ 8 mm), with and without bone augmentation procedures. Electronic (via PubMed, Web of Science, EMBASE, Cochrane Library) and manual searches were performed for articles published prior to November 2020. Only randomized controlled trials (RCTs) comparing extra-short implants and longer implants in the same study reporting survival rate with an observation period at least 1 year were selected. Data extraction and methodological quality (AMSTAR-2) was assessed by 2 authors independently. A quantitative meta-analysis was performed to compare the survival rate, marginal bone loss (MBL), biological and prosthesis complication rate. Risk of bias was assessed with the Cochrane risk of bias tool 2 and the quality of evidence was determined with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. 21 RCTs were included, among which two were prior registered and 14 adhered to the CONSORT statement. No significant difference was found in the survival rate between extra-short and longer implant at 1- and 3-years follow-up (RR: 1.002, CI 0.981 to 1.024, P = 0.856 at 1 year; RR: 0.996, CI 0.968 to 1.025, P = 0.772 at 3 years, moderate quality), while longer implants had significantly higher survival rate than extra-short implants (RR: 0.970, CI 0.944 to 0.997, P < 0.05) at 5 years. Interestingly, no significant difference was observed when bone augmentations were performed at 5 years (RR: 0.977, CI 0.945 to 1.010, P = 0.171 for reconstructed bone; RR: 0.955, CI 0.912 to 0.999, P < 0.05 for native bone). Both the MBL (from implant placement) (WMD: − 0.22, CI − 0.277 to − 0.164, P < 0.01, low quality) and biological complications rate (RR: 0.321, CI 0.243 to 0.422, P < 0.01, moderate quality) preferred extra-short implants. However, there was no significant difference in terms of MBL (from prosthesis restoration) (WMD: 0.016, CI − 0.036 to 0.068, P = 0.555, moderate quality) or prosthesis complications rate (RR: 1.308, CI 0.893 to 1.915, P = 0.168, moderate quality). The placement of extra-short implants could be an acceptable alternative to longer implants in atrophic posterior arch. Further high-quality RCTs with a long follow-up period are required to corroborate the present outcomes.Registration number The review protocol was registered with PROSPERO (CRD42020155342).

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Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1735224 ◽

2021 ◽

Author(s):

Ronnie L. Shammas ◽

Amanda R. Sergesketter ◽

Mahsa Taskindoust ◽

Sonali Biswas ◽

Scott T. Hollenbeck ◽

...

Keyword(s):

Patient Satisfaction ◽

Breast Reconstruction ◽

Free Flap ◽

Well Being ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Decision Regret ◽

History Of ◽

Implant Reconstruction

Abstract Background Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction. Methods All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction. Results Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91). Conclusion A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

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Prepectoral Direct-to-Implant Breast Reconstruction: Early Outcomes and Analysis of Postoperative Pain

Aesthetic Surgery Journal Open Forum ◽

10.1093/asjof/ojz006 ◽

2019 ◽

Vol 1 (1) ◽

Cited By ~ 1

Author(s):

Rafi Fredman ◽

Cindy Wu ◽

Mihaela Rapolti ◽

Daniel Luckett ◽

Jason Fine ◽

...

Keyword(s):

Postoperative Pain ◽

Breast Reconstruction ◽

Statistical Significance ◽

Complication Rates ◽

Level Of Evidence ◽

Trade Offs ◽

Technological Advances ◽

Significant Difference ◽

Aesthetic Results ◽

Postmastectomy Radiation Therapy

Abstract Background Direct-to-implant (DTI) breast reconstruction provides high-quality aesthetic results in appropriate candidates. Most commonly, implants are placed in the subpectoral space which can lead to pain and breast animation. Surgical and technological advances have allowed for successful prepectoral implant placement which may eliminate these trade-offs. Objectives Here we present early outcomes from 153 reconstructions in 94 patients who underwent prepectoral DTI. We sought to determine whether these patients have less postoperative pain and narcotic use than subpectoral implant or expander placement. Methods A retrospective review was performed for all prepectoral DTI reconstructions at our institution from 2015 to 2016. Data were collected on postoperative pain and narcotic use while in hospital. Results The average follow-up time was 8.5 months (range, 3–17 months) and the overall complication rate was 27% (n = 41) with the most common complications being skin necrosis (9%, n = 13) and infection (7%, n = 11). No statistically significant difference in complications was found in patients who underwent postmastectomy radiation therapy. Patients who underwent prepectoral DTI reconstruction did not have a statistically significant difference in postoperative pain and narcotic use while in-hospital compared with other techniques. Conclusion Prepectoral DTI reconstruction provides good results with similar complication rates to subpectoral techniques. Prepectoral DTI eliminates the problem of breast animation. Although our series did not reach statistical significance in pain scores or requirement for postoperative narcotics, we believe that it is an important preliminary result and with larger numbers we anticipate a more definitive conclusion. Level of Evidence: 4

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Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1692168 ◽

2019 ◽

Vol 35 (08) ◽

pp. 622-630

Author(s):

Han Gyu Cha ◽

Min Kyu Kang ◽

Hyun Ho Han ◽

Eun Key Kim ◽

Jin Sup Eom

Keyword(s):

Breast Reconstruction ◽

Ct Angiography ◽

Patient Selection ◽

Surgical Outcomes ◽

Selection Criteria ◽

Diep Flap ◽

Complication Rates ◽

Abdominal Scar ◽

Significant Difference ◽

Patient Selection Criteria

Abstract Background The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. Methods We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. Results The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was −0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. Conclusion The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

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Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

British Journal of Surgery ◽

10.1002/bjs.9847 ◽

2015 ◽

Vol 102 (9) ◽

pp. 1064-1070 ◽

Cited By ~ 15

Author(s):

R. Jeevan ◽

J. P. Browne ◽

J. Pereira ◽

C. M. Caddy ◽

C. Sheppard ◽

...

Keyword(s):

Breast Reconstruction ◽

Socioeconomic Deprivation ◽

Complication Rates ◽

Reconstruction Surgery ◽

Inpatient Complication

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0660 The Association Between Sleep-Related Breathing Disorders and Free Flap Reconstruction Surgery in Patients With Oral and Oropharyngeal Cancers During 6-Month Follow-Up

SLEEP ◽

10.1093/sleep/zsaa056.656 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A252-A252

Author(s):

L Fu-Hsin ◽

C Chan-Chi ◽

L Yu-Cheng ◽

L Wei-Shu ◽

L Cheng-Yu

Keyword(s):

Free Flap ◽

Apnea Hypopnea Index ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Sleep Related Breathing Disorders ◽

Reconstruction Surgery ◽

Breathing Disorders ◽

Significant Difference ◽

Before And After ◽

The Impact

Abstract Introduction Little was known about the association between sleep-related breathing disorders (SRBDs) and oral and oropharynx cancers (OOCs). To clarify the impact of free flap reconstruction on SRBDs, we performed a pilot study to investigate the change of SRBDs severity in patients with OOC before and after flap reconstruction surgery. Methods This study recruited 15 patients who were newly diagnosed with OOCs and expected to receive free flap reconstruction surgery. For each participant, polysomnography tests were performed repeatedly at the time of pre-operative, post-operative 1-week, and post-operative 6-month periods. Results All the subjects were male. Median age was 56 years (range 37-68). Mean of body mass index (BMI) was 24.5 (SD 5.8). Pre-operative apnea-hypopnea index (AHI) was 21.1/hour (SD 20.1). During post-operative 1-week period, BMI was 24.1(SD 5.8) and AHI was 40.2/hour (SD 27.9). During post-operative 6-month period, BMI was 23.4 (SD 3.3) and AHI was 33.3/hour (SD 21.6). Comparison between pre-operative and post-operative 6-month periods, there was no significant difference in BMI, but AHI increased significantly (21.1/hour v.s. 33.3/hour, P = 0.01). Conclusion Our study showed that OOCs patients with free flap reconstruction surgery had significantly increased AHI level during post-operative 1-week period. The SRBDs severity became partial remission after 6 months. We recommend that the head and neck cancer team should pay attention to the SRBDs issues in OOCs patients with free flap reconstruction surgery. Support

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Delivering Breast Reconstruction Information to Patients—Part 2: Women Report on Preferred Information Content

Plastic Surgery ◽

10.1177/2292550320925902 ◽

2020 ◽

Vol 28 (4) ◽

pp. 196-203

Author(s):

Natalie Jacox ◽

Carmen Webb ◽

Vishal Sharma ◽

Claire Temple-Oberle

Keyword(s):

Breast Reconstruction ◽

Mixed Methods Research ◽

Structured Interview ◽

Immediate Breast Reconstruction ◽

Reconstruction Surgery ◽

Purposeful Sampling ◽

Pros And Cons ◽

Nipple Sparing ◽

Interview Transcript ◽

Implant Reconstruction

Purpose: To determine the type of information women want to be provided in order to make an informed decision as to whether, when, and using what technique to proceed with breast reconstruction. Method: Using purposeful sampling, 19 patients who had recently undergone various breast reconstruction procedures were recruited to each participate in a 30- to 45-minute semi-structured interview. Participants shared their insights and beliefs regarding the type of breast reconstruction information they most valued prior to undergoing breast reconstruction surgery. Participants were also queried as to perceived information gaps. In some cases, the participants’ partners or support persons were also interviewed. Grounded theory and thematic analysis assisted in interview transcript analysis. Results: Eight topics were identified relating to women’s informational needs around breast reconstruction. Examples include how to weigh the pros and cons of various breast reconstruction options to decide between flap or implant reconstruction, whether there are safety concerns with immediate breast reconstruction or nipple-sparing reconstruction, and expectations and advice on how to manage possibly unexpected intimacy issues after breast reconstruction. Conclusions: Using mixed methods research methodology, 19 women reported on preoperative informational gaps relating to their recent breast reconstruction experiences. Patients report that adequate breast reconstruction information prior to breast reconstruction surgery helps them to manage their expectations, prepare for surgery and recovery, and improve postoperative satisfaction.

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1443 Comparison of Outcomes Between Immediate Direct-to-Implant Breast Reconstruction versus Two-Stage Implant Breast Reconstruction; a Systematic Review and Meta-analysis

British Journal of Surgery ◽

10.1093/bjs/znab259.225 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

O Kelly ◽

I Balasubramanian ◽

C Cullinane ◽

R Prichard

Keyword(s):

Systematic Review ◽

Breast Reconstruction ◽

Meta Analysis ◽

Capsular Contracture ◽

Tissue Expander ◽

Immediate Breast Reconstruction ◽

Two Stage ◽

Significant Difference ◽

Implant Reconstruction ◽

Implant Breast Reconstruction

Abstract Background Direct-to-implant (DTI) breast reconstruction is increasingly performed as the preferred method of immediate breast reconstruction following mastectomy. The proposed advantages of DTI over two-stage tissue expander (TE)/implant reconstruction relate to fewer surgical procedures. This systematic review and meta-analysis aims to evaluate the safety and efficacy of DTI versus conventional TE/implant breast reconstruction. Method A systematic review was performed (PubMed, Embase, Scopus) to identify relevant studies that compared outcomes between DTI and TE/Implant reconstructions. Publications up to October 2020 were included. The primary outcome was overall complication rate. Secondary outcomes included infection rate and implant loss. Results Nineteen studies, including 32,971 implant-based breast reconstructions, were analysed. Median age was 48 years. Mean BMI was 25.9. There was no statistically significant difference between the two groups. Duration of follow up ranged from 1-60 months. Overall complications were significantly more likely to occur in the DTI group (OR 1.81 [1.17-2.79]). Overall complications refers to all reported complications including seroma, haematoma, would dehiscence, infection, skin necrosis and capsular contracture. Implant loss was also significantly higher in the DTI cohort (OR 1.31 [1.12-1.78]). There was no significant difference in infection rates between the two groups. Subgroup analyses, focusing on high-powered multicentre studies showed that the risks of overall complications were significantly higher in the DTI group (OR 1.51 [1.06-2.14]). Conclusions This meta-analysis demonstrates significantly greater risk of complications and implant loss in the DTI breast reconstruction group. These findings serve to aid both patients and clinicians in the decision-making process regarding implant reconstruction following mastectomy

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A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy

Journal of Reconstructive Microsurgery ◽

10.1055/s-0040-1716846 ◽

2020 ◽

Author(s):

Adee J. Heiman ◽

Sairisheel R. Gabbireddy ◽

Vasanth S. Kotamarti ◽

Joseph A. Ricci

Keyword(s):

Radiation Therapy ◽

Breast Reconstruction ◽

Free Flap ◽

Adjuvant Radiation ◽

Complication Rates ◽

Flap Reconstruction ◽

Fat Necrosis ◽

Free Flap Reconstruction ◽

Immediate Reconstruction ◽

Delayed Reconstruction

Abstract Background Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known. Methods A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms “breast reconstruction AND (radiation OR irradiation OR radiotherapy)” were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT. Results Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group. Conclusion Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.

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Effect of Preoperative Medical Status on Microsurgical Free Flap Reconstructions: A Matched Cohort Analysis of 969 Cases

Journal of Reconstructive Microsurgery ◽

10.1055/s-0037-1607309 ◽

2017 ◽

Vol 34 (03) ◽

pp. 170-175 ◽

Cited By ~ 7

Author(s):

Paul Heidekrueger ◽

Milomir Ninkovic ◽

P. Broer ◽

Denis Ehrl

Keyword(s):

High Risk ◽

Free Flap ◽

Smoking Status ◽

Cohort Analysis ◽

Hospital Length Of Stay ◽

Complication Rates ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Medical Status ◽

Significant Difference

Background Free tissue transfers have become standard for a wide variety of reconstructive purposes. In an era of increasing economic pressure, it is important to precisely define appropriate candidates and indications for a complex surgery to optimize efficiency and patient outcomes. This study evaluates the feasibility to perform microsurgical procedures in a medically compromised patient cohort at a major academic microsurgical center. Methods Within 7 years, 897 patients underwent 969 microvascular free flap reconstructions. The data were retrospectively screened for patients' demographics, perioperative details, flap survival, surgical complications, and outcomes. The cases were divided into two groups in “low-risk” (American Society of Anesthesiologists [ASA] I and II) or “high-risk” (ASA III and IV) as per the preoperative medical status classified according to the ASA score of physical status. Results Despite the significantly high prevalence of hypertension, peripheral artery disease, diabetes, obesity, and smoking status in the “high-risk” group (p < 0.05), there was no significant difference in the rate of surgical or medical complications, in operative times regarding overall as well as different flap entities, flap failures, need for revision surgery, or hospital length of stay between the two patient groups during our 3-months follow-up period (p > 0.05). Conclusion In this study, free flap reconstruction in medically compromised patients was not associated with higher rates of revision surgeries, overall complication rates, or surgery-related costs. Complex microsurgical free flap reconstruction can therefore also be advocated in patients with high preoperative risk constellation.

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