Research Interests: Surgery, Photography, Medicine, Plastic and Reconstructive Surgery, Anatomy, and 15 moreHumans, Female, Breast Reduction, Three Dimensional Imaging, Plastic, Breast, Reduction, Clinical Sciences, Middle Aged, Adult, And, Three Dimensional, Sensitivity and Specificity, Cohort Studies, and Postoperative care
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Background: Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remain limited data on surgical complications associated with reduction mammaplasty in adolescents, which may... more
Background: Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remain limited data on surgical complications associated with reduction mammaplasty in adolescents, which may not be concordant with those cited for adults seeking reduction mammaplasty. Methods: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases for symptomatic macromastia in patients aged 20 years and younger over a 7-year period from 2014 to 2021. Results: One hundred sixty total breasts were analyzed in 80 patients. Mean age was 18.3 ± 1.4 years, with an age range from 15 to 20 years. Mean body mass index was 27.17 ± 5.49 kg/m2. Mean reduction weight was 584.79 ± 261.19 g. A medial pedicle was used in 91%, and an inferior pedicle was used in 9%. For skin incision, a Wise pattern was used in 60%, and a short-scar was used in 40%. There was a 16.3% rate of any surgical complication, which included wound healing by secondary intention treated with local wound care. There were no significant risk factors for a surgical complication in reduction mammaplasty, and no differences in surgical complications related to skin incision type, pedicle use, or breast reduction weight. Performance of a receiver operating characteristic curve for age at surgery and complication demonstrated that there was no age cutoff where the risk of surgical complication was appreciably increased or decreased. Conclusions: Age was not identified as a risk factor for surgical complications in adolescent reduction mammaplasty. Overall, complication rates were very low and minor in nature for adolescent reduction mammaplasty, with no significant risk factors identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
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Background: The female breast is a subject of significant focus within plastic surgery. Little work to date has examined public perceptions of attractiveness with respect to breast anatomy and morphology. This study provides a... more
Background: The female breast is a subject of significant focus within plastic surgery. Little work to date has examined public perceptions of attractiveness with respect to breast anatomy and morphology. This study provides a comprehensive assessment of anatomic and aesthetic breast characteristics valued by the general population. Methods: A single-institution retrospective review was conducted of patients presenting for aesthetic or reconstructive breast surgery between 2009 and 2019. A cohort of 25 patients were included in a nationwide survey designed to assess subjective impressions of overall “breast attractiveness.” Survey responses were assessed, and the five patients with the highest mean scores were identified. An in-depth analysis of this subgroup was performed, evaluating anatomic metrics on both two-dimensional photographs and three-dimensional imaging. Statistical analysis examined correlations between objective breast characteristics and subjective perceptions of “attractiveness.” Results: There were 1021 survey responses. Across the entire patient cohort, the mean age was 47.4 years and mean BMI was 24.9 kg/m2. On a five-point Likert scale, the mean “breast attractiveness” score for the highest-scoring subgroup patients (n = 5) was 3.1 ± 0.1. Within this group, all patients had minimal ptosis and a projected contour. Average breast size was moderate, with mean volume of 299.4 ± 115.8 cm3. Conclusions: This study reverse engineers the aesthetically appealing female breast, beginning with overall impressions of attractiveness and subsequently analyzing the influence of objective anatomic parameters on subjective perceptions. In surveying a large and diverse population, moderately sized, projected breasts with upper pole fullness were found to be associated with increased “attractiveness” scores.
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193 Background: Breast cancer resection strives for less radical approaches that offer superior aesthetic results without compromising oncologic safety. Nipple-sparing mastectomy (NSM) has gained popularity, but usually has been offered... more
193 Background: Breast cancer resection strives for less radical approaches that offer superior aesthetic results without compromising oncologic safety. Nipple-sparing mastectomy (NSM) has gained popularity, but usually has been offered to smaller breasted and minimally ptotic women without history of extensive breast surgery. We present a series of nine nipple-sparing mastectomies following reduction mammoplasty. Methods: Charts of patients who underwent NSM following reduction mammoplasty at the NYU Medical Center from 2006 through 2011 were reviewed. Outcomes measured include post-operative complications, breast cancer recurrence, presence of cancer in the nipple-areolar complex, and nipple-areolar complex viability. Results: In total, the records of 235 (145 prophylactic, 90 therapeutic) NSM patients at NYU Medical Center were reviewed. Six patients for a total of 9 breasts had NSM following reduction mammoplasty. This subset of patients had a mean age of 46.2, mean BMI of 25.1, no history of diabetes and 1 smoker. Seven of 9 breasts were therapeutic resections and 2 of 9 were prophylactic. Time elapsed between reduction mammoplasty and NSM ranged from 33 days to 11 years. The majority of resections were in Stage 0 patients (6/9) with 1/9 in Stage I and 2/9 in Stage IIA. In all cases, prior reduction mammoplasty incisions were utilized for NSM. Eight patients were reconstructed immediately with tissue expanders, and 1 patient had a latissimus dorsi flap with immediate implant. Complications included 1 hematoma requiring evacuation and 1 displaced implant requiring revision. There were no positive subareolar biopsies and 100% nipple viability. Mean follow-up time was 9.4 months. Conclusions: Our experience demonstrates that NSM can be offered following reduction mammoplasty with comparable reconstructive outcomes to NSM alone. Reduction mammoplasty followed by NSM has potential as a reconstructive tool in prophylactic cases unsuited for primary NSM.
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Research Interests: Surgery, Medicine, Plastic and Reconstructive Surgery, Prospective studies, Humans, and 15 morePlacebo, Female, Anesthesia, Plastic, Clinical Sciences, Postoperative pain, Adult, And, Randomized Controlled Trial, Narcotic, Ambulatory Surgical Procedures, Pain Measurement, Bupivacaine, Prospective Cohort Study, and Intraoperative Care
Research Interests: Surgery, Plastic Surgery, Treatment Outcome, Medicine, Plastic and Reconstructive Surgery, and 14 moreHumans, Female, Follow-up studies, Mastectomy, Clinical Sciences, Middle Aged, Adult, Retrospective Studies, Postoperative Complications, Areola, Breast Neoplasms, Nipples, Mastopexy, and Surgical Flaps
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Immediate implant-based breast mound reconstruction offers many advantages over staged implant reconstruction techniques. For large volume breast reconstruction, a Wise-pattern skin resection may provide very good aesthetic results;... more
Immediate implant-based breast mound reconstruction offers many advantages over staged implant reconstruction techniques. For large volume breast reconstruction, a Wise-pattern skin resection may provide very good aesthetic results; however, the submuscular implant pocket is inadequate to cover the inferior pole of the breast. In this patient population, the risk of implant exposure from T-point breakdown is significant. We present our technique of Wise-pattern breast reconstruction using AlloDerm (LifeCell, Branchburg, NJ) and a vascularized dermal-subcutaneous pedicle (DSP) to augment the volume and quality of immediate breast implant coverage, particularly in the area of the T-point suture lines. We reviewed a series of 20 consecutive patients with large breasts who were treated with an immediate implant reconstruction of greater than 400 mL volume using the Wise-pattern with DSP. Preoperative and postoperative 3-dimensional surface scan studies were performed to evaluate breast symmetry. The average volume of breast reconstruction in this study group was 458 mL. T-point breakdown occurred in 5 patients (25%). These patients were treated with local wound care and healed with an excellent aesthetic result. None of these patients required implant removal, implant exchange, or operative debridement. Pre- and postoperative 3-dimensional surface scan analysis of these patients demonstrated comparable differences between the affected and unaffected sides in women undergoing immediate breast implant reconstruction when compared with a matched group of patients undergoing 2-stage breast reconstruction with tissue expanders. Wise-pattern skin-reducing mastectomy is an excellent strategy to provide an aesthetically pleasing, immediate implant breast reconstruction. This technique provides breast symmetry that is at least comparable to that of tissue expander-based, staged implant reconstructions. The reliability of the Wise-pattern technique is significantly improved with the addition of AlloDerm to the muscular pocket and a vascularized DSP to preserve the integrity of the reconstruction in the presence of T-point breakdown.
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Background: Nipple-sparing mastectomy with immediate, permanent implant reconstruction offers patients a prosthetic “breast in a day” compared to tissue expander techniques requiring multiple procedures. Methods: Patients undergoing... more
Background: Nipple-sparing mastectomy with immediate, permanent implant reconstruction offers patients a prosthetic “breast in a day” compared to tissue expander techniques requiring multiple procedures. Methods: Patients undergoing nipple-sparing mastectomy with immediate, permanent implant reconstruction were reviewed with patient demographics and outcomes analyzed. Results: Of 842 nipple-sparing mastectomies from 2006 to June of 2015, 160 (19.0 percent) underwent immediate, permanent implant reconstruction. The average age and body mass index were 46.5 years and 23.3 kg/m2. The majority of implants were either Allergan Style 20 (48.1 percent) or Style 15 (22.5 percent). The average implant size was 376.2 ml, and 91.3 percent of reconstructions used acellular dermal matrix. The average number of reconstructive operations was 1.3. Follow-up was 21.9 months. The most common major complication was major mastectomy flap necrosis (8.1 percent). The rate of reconstructive failure was 5.6 percent and implant loss was 4.4 percent. The most common minor complication was minor mastectomy flap necrosis (14.4 percent). The rates of full-thickness and partial-thickness nipple necrosis were 4.4 and 7.5 percent, respectively. Age older than 50 years (p = 0.0276) and implant size greater than 400 ml (p = 0.0467) emerged as independent predictors of overall complications. Obesity (p = 0.4073), tobacco use (p = 0.2749), prior radiation therapy (p = 0.4613), and acellular dermal matrix (p = 0.5305) were not associated with greater complication rates. Conclusion: Immediate, permanent implant reconstruction in nipple-sparing mastectomy provides patients with a breast in a day in less than two procedures, with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Summary: As a biologic product derived from human tissue, acellular dermal matrices did not require premarket approval for their initial use as a soft-tissue support product. Since their first use in breast surgery, acellular dermal... more
Summary: As a biologic product derived from human tissue, acellular dermal matrices did not require premarket approval for their initial use as a soft-tissue support product. Since their first use in breast surgery, acellular dermal matrices have allowed for numerous advances in breast reconstruction. They quickly gained popularity in breast surgery and are used frequently in various applications. During an investigation into potential factors leading to breast implant–associated anaplastic large-cell lymphoma, the U.S. Food and Drug Administration made an official statement that acellular dermal matrices were not approved for use in breast reconstruction and that using them in breast surgery was considered off-label. This special topic article details the history of acellular dermal matrices in breast surgery and describes the ongoing evolution of the relationship between the U.S. Food and Drug Administration and acellular dermal matrices.
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Background: The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial... more
Background: The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial pedicle technique in a large series. Methods: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. All consecutive superomedial pedicle reduction mammaplasty cases for benign symptomatic macromastia were included. Results: A total of 462 breasts were analyzed. Mean age was 38.3 ± 13.38 years, mean body mass index was 28.5 ± 4.95, and mean reduction weight was 644.4 ± 299.16 g. Regarding surgical technique, a superomedial pedicle was used in all cases; Wise-pattern incision was used in 81.4%, and short-scar incision was used in 18.6%. The mean sternal notch–to-nipple measurement was 31.2 ± 4.54 cm. There was a 19.7% rate of any complication, the majority of which were minor in nature, including any wound healing complications treated with local wound care (7.5%) and scarring with intervention in the office (8.6%). There was no statistically significant difference in breast reduction complications and outcomes using the superomedial pedicle, regardless of sternal notch–to-nipple distance. Body mass index (P = 0.029) and breast reduction specimen operative weight (P = 0.004) were the only significant risk factors for a surgical complication, and with each additional gram of reduction weight, the odds of a surgical complication increased by 1.001. Mean follow-up time was 40.5 ± 7.1 months. Conclusion: The superomedial pedicle is an excellent option for reduction mammaplasty, portending a favorable complication profile and long-term outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Background: Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking... more
Background: Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. Methods: A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes—including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope—were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. Results: Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. Conclusions: Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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highest with 87% of patients stating decreased nasal obstruction. This was followed by electrocautery (86.7%), laser cautery (85.4%), submucousal resection (80.23%), total turbinectomy (69%), and cryotherapy (60%). Submucousal resection... more
highest with 87% of patients stating decreased nasal obstruction. This was followed by electrocautery (86.7%), laser cautery (85.4%), submucousal resection (80.23%), total turbinectomy (69%), and cryotherapy (60%). Submucousal resection and laser cautery were found to have the greatest change in nasal airway resistance, .75 Pa/cm, followed by total turbinectomy (.69), cryotherapy (.6), and partial turbinectomy (.55). Surgeons were found to prefer partial turbinectomy (47.65%) followed by turbinate outfracture (42.5%). Post-operative bleeding and atrophic rhinitis was most commonly reported with total turbinectomy (12.9% and 39% respectively) while synchiae and crusting were most prevalent with electrocautery (34% and 63% respectively). Conclusion: Many approaches toward treating inferior turbinate hypertrophy in rhinoplasty have been utilized in the literature. A systematic review of the evidence reveals that partial turbinectomy appears to provide largest decrease in nasal obstruction, while total turbinectomy and electrocauterization have higher levels of complications.
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Background Higher body mass index (BMI) has been shown to increase postoperative complications in autologous breast reconstruction. However, the correlation with flap weight is unknown. Here, we explore the relationship of flap weights... more
Background Higher body mass index (BMI) has been shown to increase postoperative complications in autologous breast reconstruction. However, the correlation with flap weight is unknown. Here, we explore the relationship of flap weights and complication rates in patients undergoing microvascular breast reconstruction. Methods Retrospective chart review identified all patients undergoing microvascular breast reconstruction with abdominally based flaps at a single institution between November 2007 and April 2013. Breasts with documented flap weight and 1-year follow-up were included. Patients undergoing stacked deep inferior epigastric perforator flaps were excluded. Breasts were divided into quartiles based on flap weight and examined by demographics, surgical characteristics, complications, and revisions. Results A total of 130 patients undergoing 225 flaps were identified. Patients had a mean age of 50.4 years, mean BMI of 27.1 kg/m(2), and mean flap weight of 638.4 g (range: 70-1640 g). Flap weight and BMI were directly correlated. Flaps were divided into weight-based quartiles: first (70-396 g), second (397-615 g), third (616-870 g), and fourth (871-1640 g). There were no associations between flap weight and incidences of venous thrombosis, arterial thrombosis, hematoma, flap loss, fat necrosis, or donor site hernia. However, increased flap weight was associated with increased rate of donor site wound healing problems in both univariate and multivariate analysis. Conclusions Increased flap weight is not associated with added flap complications among patients undergoing microvascular breast reconstruction, however, patients with flaps of 667.5 g or more are more likely to have donor site healing problems. The success and evidence contrary to previous studies may be attributed to surgeon intraoperative flap choice.
Research Interests: Surgery, Obesity, Microsurgery, Medicine, Humans, and 13 moreFemale, Body Mass Index, Risk factors, Clinical Sciences, Middle Aged, Retrospective Studies, Risk Factors, Fat Necrosis, Breast Reconstruction, Univariate Analysis, Postoperative Complications, Reconstructive Microsurgery, and free tissue flaps
Purpose: Nipple and/or areola-sparing mastectomy as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach... more
Purpose: Nipple and/or areola-sparing mastectomy as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. Methods: We reviewed 58 consecutive nipple and/or areola-sparing mastectomies performed through a lateral IMF incision with immediate implant-based reconstruction, with or without tissue expansion, between June 2008 and February 2011. Prior to incision, breasts were lightly tumesced with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three-dimensional (3D) photographs assessed changes in volume, antero-posterior projection, and ptosis. Retroareolar/nipple tissue underwent routine intraoperative frozen section analysis in cancer cases. Results: Mean patient age was 44 years, and mean follow-up time was 14 months. Depending upon the judgment of the oncologic surgeon, 44 (76%) mastectomies were nipple/areola-sparing, and 14 (24%) were areola-sparing. Thirteen mastectomies (22%) were therapeutic, the remaining 45 mastectomies (78%) were prophylactic. Five of the nine sentinel lymph node biopsies (56%) were performed through the lateral IMF incision without the need for a counter-incision. Acellular dermal matrix was used in 44 (76%) breasts. Average permanent implant volume was 313 cc (range 170 to 750 cc), and average fat grafting volume was 90 cc (range 36 to 177 cc). Mastectomy flap necrosis, requiring operative debridement, occurred in three breasts (5%). One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Of the 44 nipple/areola sparing mastectomies, three (7%) required operative debridement and reconstruction for partial nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin or nipple necrosis (p = 0.65). Morphologic outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic (196 vs. 248 cc, 80 vs. 90 mm, 146 vs. 134 mm, p < 0.01 for each parameter). Conclusion: Excellent results can be achieved with immediate implant-based reconstruction of nipple and/or areola-sparing mastectomy through a lateral IMF incision. NAC survival is reliable, and complication rates are low. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-09.
Research Interests: Surgery, Cancer, Medicine, Mastectomy, Implant, and 3 moreBreast Reconstruction, Areola, and Mastopexy
Background: Nipple-sparing mastectomy (NSM) has gained popularity, but remains contoversial as the procedure's reconstructive outcomes and oncologic safety are still somewhat uncertain. Methods: We retrospectively reviewed the New... more
Background: Nipple-sparing mastectomy (NSM) has gained popularity, but remains contoversial as the procedure's reconstructive outcomes and oncologic safety are still somewhat uncertain. Methods: We retrospectively reviewed the New York University-Langone Medical Center experience with NSM from 2006–2011. Outcomes measured include post-operative complications, breast cancer recurrence, presence of cancer at the nipple-areolar complex, and nipple-areolar complex viability. Results: Our data include patients who underwent NSM from 2006–2011. In total, the records of 235 (145 prophylactic, 90 theraputic) NSM at NYULMC were reviewed. Our reconstructive dta included all forms of reconstruction, including 144 tissue expanders, 74 microvascular free flaps, 16 immediate implants, and 1 combination latissimus dorsi flap with implant. Mean follow-up time was 19 months. No differences existed between the theraputic and prophylactic breast patients. The major complication rate of 4.3% (10/235) included 4 intraoperative hematoma evacuations, 1 flap anastomosis revision, and 3 explanted implants. One patient expired 4 months following surgery secondary to progression of disease. The microvascular free flap loss rate for this group was 0. Minor complications in 6.8% of patients consisted of implant exchange for asymmetry, operative revision of partial flap necrosis, intravenous antibiotics for infection, and 1 non-operative hematoma. In total, 5.9% of nipples were resected due to malignant or premalignant disease. There were 3 positive intraoperative biopsies with 9 additional biopsies positive on final pathology. To date, there have been no recurrences involving the nipple-areolar complex. The viability rate for the remaining nipples was 93.2% with1.7% of nipples undergoing complete necrosis, 3.8% partial necrosis, and 1.3% undergoing epiderolysis. Conclusions: This experience with NSM demonstrates the in a carefully selected cohort, oncologic safety and reconstructive outcome are comparable to the current standard of total mastectomy. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-07.
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Background: Advances in breast cancer screening and treatment have fostered the use of surgical procedures that increasingly optimize cosmetic outcome, while ensuring oncologic safety remains the primary concern of the oncologic surgeon.... more
Background: Advances in breast cancer screening and treatment have fostered the use of surgical procedures that increasingly optimize cosmetic outcome, while ensuring oncologic safety remains the primary concern of the oncologic surgeon. The role of nipple-sparing mastectomy (NSM) for risk-reducing surgery and breast cancer is evolving. It can be difficult to demonstrate involvement of the nipple-areolar complex (NAC) preoperatively, and and in this report we examine the utility of intraoperative subareolar frozen section (FS). Methods: Records of patients undergoing NSM at the NYU Langone Medical Center from 2006–2011 were reviewed retrospectively. Use of subareolar FS was at surgeon's discretion. Results: 237 NSM were performed (146 prophylacytic, 91 theraputic). FC was not utilized in 58 mastectomies (28 prophylactic), with 2 (+) on paraffin. Among the remaining 180 mastectomies, 11 biopsies were (+)(7.2%); 5 subareolar biopsies were (+) on FS and paraffin histologic slides (PS)(2.8%); 6 were negative on FS and (+) on PS. Among the 3 prophylactic NSM with (+) subareolar biopsies there was 1 (+) FS, 1 (−) FS, and 1 with no FS performed. There were no false (+) FS. Four of the 5 patients with (+)FS underwent simultaneous excision of the NAC. The 5th patient had atypia on FS and DCIS on PS, and returned to the OR during the same hospitalization for removal of NAC. The remaining patients underwent subsequent excision of the NAC either during planned 2nd stage reconstruction or following completion of chemotherapy. 8 NAC were free of disease and 5 were positive for in situ or invasive disease. There has been no local recurrence in these patients to date. Conclusions: The rate of NAC involvement is low, 5.5% in this series, and FS, while utilized in the majority of these cases, detected only 46% of subareolar disease. While FS can direct intraoperative decision making, the predictive power is low, and these considerations must be addressed in preoperative patient discussions. Furthermore, among those patients with (+) subareolar biopsies, only 39% had residual disease on NAC excision. Thus, optimal oncologic management of the NAC must still be considered an unresolved issue. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-03.
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studies that analyzed original data. 1 Impact, as measured by citations, was also higher for COVID-19–related articles, suggesting there was increased discussion among academics about the pandemic and its ramifications on plastic surgery.... more
studies that analyzed original data. 1 Impact, as measured by citations, was also higher for COVID-19–related articles, suggesting there was increased discussion among academics about the pandemic and its ramifications on plastic surgery. The impact and influence of the COVID-19 pandemic were felt by the plastic surgery community worldwide and also depicted in the literature.
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Background: Implant-based breast reconstruction has evolved, with a recent resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been elucidated fully among the total submuscular, dual-plane,... more
Background: Implant-based breast reconstruction has evolved, with a recent resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been elucidated fully among the total submuscular, dual-plane, and prepectoral planes of implant placement. Methods: All immediate implant-based breast reconstructions from March of 2017 through August of 2019 were reviewed retrospectively. Cases were divided into total submuscular, dual-plane, and prepectoral cohorts. Demographics, operative techniques, and reconstructive outcomes and complications were compared among groups. Results: A total of 826 cases (510 patients) were identified and divided into total submuscular (n = 392), dual-plane (n = 358), and prepectoral (n = 76) cohorts. Average follow-up for all patients was 27 months. The prepectoral cohort had a higher average body mass index and rate of previous reduction or mastopexy. Overall complications were lowest in the total submuscular group, although this difference was not statistically significant. Major infection occurred more frequently in the dual-plane group compared with the total submuscular cohort. The prepectoral cohort had a significantly increased incidence of wound dehiscence than the total submuscular group; both the dual-plane and prepectoral groups had higher rates of seroma formation and explantation compared with the total submuscular group. Conclusions: Overall reconstructive complication rates were comparable among the cohorts. Compared with those undergoing total submuscular reconstruction, the dual-plane cohort was more likely to develop a major infection or require explantation, whereas the prepectoral group had significantly higher rates of isolated dehiscence, seroma formation, and explantation. This suggests that the absence of overlying vascularized muscle may lead to an inherent inability to tolerate wound-healing complications, although further research is needed to clarify these observations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Introduction: The COVID-19 pandemic posed unique challenges for breast reconstruction. Many professional organizations initially placed restrictions on breast reconstruction, leading surgeons to conceive innovative protocols for offering... more
Introduction: The COVID-19 pandemic posed unique challenges for breast reconstruction. Many professional organizations initially placed restrictions on breast reconstruction, leading surgeons to conceive innovative protocols for offering breast reconstruction. This study reviewed the current evidence on breast reconstruction during the COVID-19 pandemic to provide guidance for surgeons facing future crises. Methods: The MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were searched for studies (1) describing implant and autologous breast reconstruction following mastectomy and (2) occurring during or pertaining to the COVID-19 pandemic. Results: Of the 1347 studies identified, 26 were included. Studies discussed type of reconstruction (18, 69%), complications (11, 42%), timing of reconstruction (10, 38%), protocols (10, 38%), COVID-19 screening (7, 27%), and length of hospital stay (7, 27%). The type of reconstruction varied depending on the stage of the pandemic: early on, autologous breast reconstruction was halted to preserve resources, but was later resumed. Within implant-based reconstruction, direct-to-implant was favored over serial tissue expansion. Several protocols were developed, with many emphasizing multidisciplinary collaborations for patient selection, use of specialized measures to reduce risk of COVID-19 transmission, and optimization of same-day discharge. Complication rates following breast reconstruction were similar to pre-pandemic rates. Conclusions: The COVID-19 pandemic has forever changed the landscape of breast reconstruction by raising important questions about delivery of care, cost, and resource utilization. The findings of this review may inform surgeons as they plan for similar future crises or strive for improved patient care and efficacy even during nonpandemic times.
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Background: The majority of two-stage prepectoral breast reconstruction has been described utilizing acellular dermal matrix (ADM). Although reports of prepectoral breast reconstruction without ADM exist, there is a paucity of comparative... more
Background: The majority of two-stage prepectoral breast reconstruction has been described utilizing acellular dermal matrix (ADM). Although reports of prepectoral breast reconstruction without ADM exist, there is a paucity of comparative studies. Methods: A single-institution retrospective review was performed of consecutive patients undergoing immediate prepectoral two-stage breast reconstruction with tissue expanders from 2017 to 2019. Short-term reconstructive and aesthetic complications were compared between cases that utilized ADM for support and those that did not. Results: In total, 76 cases (51 patients) were identified, of which 35 cases utilized ADM and 41 did not. Risk factors and demographics were similar between the two cohorts with the exception of body mass index, which was higher in the ADM cohort (29.3 versus 25.4, P = 0.011). Average follow-up length was also longer in patients who received ADM (20.3 versus 12.3 months, P < 0.001). Intraoperative expander fill ...
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Introduction The COVID-19 pandemic dramatically changed the delivery of breast cancer care. The objective of this study was to quantify the effect of the pandemic on breast cancer screening, treatment, and reconstruction at a single... more
Introduction The COVID-19 pandemic dramatically changed the delivery of breast cancer care. The objective of this study was to quantify the effect of the pandemic on breast cancer screening, treatment, and reconstruction at a single institution in New York City. Methods A retrospective chart review was conducted to determine the number of mammograms, lumpectomies, mastectomies, and breast reconstruction operations performed between January 1, 2019 through June 30, 2021. Outcomes analyzed included changes in mammography, oncologic surgery, and breast reconstruction surgery volume before, during and after the start of the pandemic. Results Mammography volume declined by 11% in March-May of 2020. Oncologic breast surgeries and reconstructive surgeries similarly declined by 6.8% and 11%, respectively, in 2020 compared to 2019, reaching their lowest levels in April 2020. The volume of all procedures increased during the summer of 2020. Mammography volume in June and July 2020 were found to be at pre-COVID levels, and in October-December 2020 were 15% higher than in 2019. Oncologic breast surgeries saw a similar rebound in May 2020, with 24.6% more cases performed compared to May 2019. Breast reconstruction volumes increased, though changes in the types of reconstruction were noted. Oncoplastic closures were more common during the pandemic, while two-stage implant reconstruction and immediate autologous reconstruction decreased by 27% and 43% respectively. All procedures are on track to increase in volume in 2021 compared to 2020. Conclusion The COVID-19 pandemic reduced the volume of breast cancer surveillance, surgical treatment and reconstruction procedures. While it is reassuring that volumes have rebounded in 2021, efforts must be made to emphasize screening and treatment procedures in the face of subsequent surges, such as that recently attributable to the Delta and Omicron variants.
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Background: Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking... more
Background: Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. Methods: A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes—including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope—were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. Results: Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p &lt; 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p &lt; 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p &lt; 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. Conclusions: Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.