Blog

• Autologous fat grafting:
  • Is a procedure to transfer fat from one part of the patient’s body to another without requiring microvascular anastomosis
  • The graft initially takes similar to a skin graft, depending on the surrounding tissue bed before new blood vessels form
  • The grafted tissue is at risk for ischemia or fat necrosis:
    • As a result, there may be both palpable changes (e.g., cyst) or radiographic changes (e.g., calcifications) following fat grafting:
      • These have benign appearance on mammogram and are generally distinguishable from malignancy but may prompt additional imaging
• Retrospective data suggest fat grafting does not interfere with cancer screening or detection
• Fat grafting can be performed for all types of reconstruction, including primary defects as in lumpectomy, asymmetry, contour changes after radiation, or contour irregularity over an implant or tissue flap:
  • To date, there have been no clinical studies that demonstrate an increase in local regional recurrence in patients who have undergone fat grafting after breast cancer treatment
• There is debate as to whether there is an ideal time to perform fat grafting:
  • But it is not routinely performed at the same time as lumpectomy or mastectomy:
    • Especially if radiation is indicated, as the tissue grafts will be susceptible to radiation injury
• Finally, graft resorption is possible following the procedure, and therefore patients should be counseled that more than one operation may be necessary to achieve the desired result
• References
  • Khouri RK Jr, Khouri RK. Current clinical applications of fat grafting. Plast Reconstr Surg 2017;140(3):466e-486e.
  • Agha RA, Fowler AJ, Herlin C, Goodacre TE, Orgill DP. Use of autologous fat grafting for breast reconstruction: a systematic review with meta-analysis of oncological outcomes. J Plast Reconstr Aesthet Surg. 2015;68(2):143-161.

• The innervation of the nipple areolar complex (NAC):
  • Is from the anterior and lateral branches of the 3^rd, 4^th, and 5^th intercostal nerves:
    • Of which the lateral cutaneous branch of the 4^th intercostal is dominant
• This nerve has the greatest risk of injury during a resection of the central lower pole of the breast:
  • A superior pedicle, with resection of the lower pole:
    • Has the highest incidence of NAC sensory compromise
  • All patients should be advised that there is a risk of permanent loss of sensation
• References
  • Riccio CA, Zeiderman MR, Chowdhry S, Brooks RM, Kelishadi SS, Tutela JP, et al. Plastic surgery of the breast: keeping the nipple sensitive. Eplasty. 2015;15:e28.
  • Chiummariello S, Angelisanti M, Arleo S, Alfano C. Evaluation of the sensitivity after reduction mammoplasty. Our experience and review of the literature. Ann Ital Chir.2013;84(4):385-388.
  • Schlenz I1, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg. 2005;115(3):743-751.

• Periprosthetic fluid collections:
  • Occurring more than 1 year after implantation:
    • Should be evaluated to rule out breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
• Diagnosis of BIA-ALCL:
  • Is made by aspiration of the periprosthetic fluid:
    • Usually performed by fine needle aspiration:
      • Under ultrasound guidance
    • A sample of 50 ml or greater is sufficient to establish a diagnosis by CD30 immunohistochemistry:
      • CD30 is a cell surface protein expressed by roughly 5% of normal circulating T-cells:
        • However, BIA-ALCL demonstrates confluent staining of CD30
• Open biopsy:
  • Is more invasive, and the capsule may be negative even in the presence of disease
• Therefore, effusion FNA is preferred for diagnosis
• Plastic surgery evaluation:
  • Is not appropriate or necessary
• Mammogram evaluation is non-specific for a disease process and is not indicated with an obvious fluid collection
• References
  • Clemens MW, Horwitz S. NCCN Consensus Guidelines for the diagnosis and management of breast implant-associated anaplastic large cell lymphoma. Aesth Surg J. 2017;37(3):285-289.
  • Brody GS, Deapen D, Taylor CR. Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases. Plast Reconstr Surg. 2015;135(3):695-705.
  • Horwitz SM, Ansell SM, Ai WZ, Barnes J, Barta SK, Choi M, et al. NCCN guidelines insights: t-cell lymphomas, version 2.2018. J Natl Compr Canc Netw. 2018;16(2):123-135.

• Several studies have concluded that a prior mammaplasty procedure (at least 3 months prior) has a negligible effect on the nipple necrosis rate following a nipple-sparing mastectomy
• References
  • Alperovich M, Tanna N, Samra F, Blechman KM, Shapiro RL, Guth AA, et al. Nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy: how safe is it? Plast Reconstr Surg. 2013;131(5):962-967.
  • Spear SL, Rottman SJ, Seiboth LA, Hannan CM. Breast reconstruction using a staged nipple-sparing mastectomy following mastopexy or reduction. Plast Reconstr Surg. 2012;129(3):572-581.
  • Frederick MJ, Lin AM, Neuman R, Smith BL, Austen WG Jr, Colwell AS. Nipple-sparing mastectomy in patients with previous breast surgery: comparative analysis of 775 immediate breast reconstructions. Plast Reconstr Surg. 2015;135(6):954e-962e.

• Disease located in the inferior hemisphere of the breast:
  • Can be easily incorporated into a Wise pattern reduction mammoplasty

• Split reduction techniques:
  • Are best used for disease located in the upper inner or upper outer quadrants requiring skin excision due to the proximity of the tumor to the skin
  • With a split reduction technique:
    • The lateral (for upper outer quadrant cancers) or medial (for upper inner quadrant cancers) triangle of the Wise pattern is not positioned at the base of the breast:
      • But instead advanced up onto the breast where the area of disease was removed
• Donut mastopexy:
  • Is best used in patients with grade 1 ptosis with the area of disease is located close to the nipple areolar complex

• The radial ellipse lumpectomy:
  • Is useful for lateral tumors
  • With this technique a radial ellipse of skin and breast parenchyma is excised full thickness
  • This technique however does not improve significant ptosis

• References
  • Savalia NB, Silverstein MJ. Oncoplastic breast reconstruction: patient selection and surgical techniques. J Surg Oncol. 2016;113(8):875-882.
  • Silverstein MJ, Mai T, Savalia N, Vaince F, Guerra L. Oncoplastic breast conservation surgery: the new paradigm. J Surg Oncol. 2014;110(1):82-89.
  • Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to partial mastectomy: an overview of volume-displacement techniques. Lancet Oncol.2005;6(3):145–57.
  • Clough KB, Ihrai T, Oden S, Kaufman G, Massey E, Nos C. Oncoplastic surgery for breast cancer based on tumour location and a quadrant-per-quadrant atlas. Br J Surg. 2012;99(1):1389-1395

• Donut mastopexy:
  • Is best used to address small to medium cancers centrally located in any quadrant
• Results are best in patients with:
  • Grade 1 ptosis with enlarged nipple areola complex
• This approach in patients with significant ptosis:
  • Will result in flattening of the central breast and would be better treated with other onocoplastic techniques
• Treatment of triple negative breast cancers:
  • Should consider neoadjuvant chemotherapy prior to surgical excision
• Young patients with triple negative breast cancer:
  • Also should consider hereditary risk assessment:
    • As this may alter their decision regarding breast conservation
• Patients with a history of prior breast cancer treated with adjuvant radiation therapy:
  • Should not consider breast conservation unless there are special circumstances
• References
  • Savalia NB, Silverstein MJ. Oncoplastic breast reconstruction: patient selection and surgical techniques. J Surg Oncol. 2016;113(8):875-882.
  • Piper M, Peled A, Sbitany H. Oncoplastic breast surgery: current strategies. Gland surg. 2015;4(2):154-163.
  • Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010;17(5):1375-1391.
  • Omarini C, Guaitoli G, Pipitone S, Moscetti L, Cortesi L, Cascinu S, et al. Neoadjuvant treatments in triple-negative breast cancer patients: where we are now and where we are going. Cancer Manag Res. 2018;10:91-103.

• In general, patients with significant ptosis of the breast:
  • Obtain better cosmetic results with a reduction mammoplasty compared to donut or Benelli mastopexy
• Lesions distant to the nipple areolar complex:
  • Can be difficult to access through a mastopexy incision

• References
  • Lebovic GS. Oncoplastic surgery: a creative approach to breast cancer management. Surg Oncol Clin N Am. 2010;19(3): 567-580.
  • Piper M, Peled A, Sbitany H. Oncoplastic breast surgery: current strategies. Gland Surg. 2015;4(2):154-163.
  • Clough, KB, Kaufman, GJ, Nos, C, Buccimazza, I, Sarfati, IM. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 2010;17(5):1375-1391.
  • Clough KB, Benyahi D, Nos C, Charles C, Sarfati I. Oncoplastic surgery: pushing the limits of breast-conserving surgery. BreastJ. 2015;21(2):140-146.

• A recent study by Liang et al:
  • Showed that in patients undergoing contralateral breast procedures at the time of oncoplastic breast-conserving surgery:
    • 16.5% were found to have high-risk pathology in the contralateral breast:
      • With almost 5% of these being cancer
  • Larger studies from Europe have shown the contralateral occult malignancy rate:
    • To be 1% to 5%:
      • This rate of occult disease is higher than the reported occult malignancy rate in patients who are undergoing cosmetic reduction mammoplasty
  • Orientation of the specimen(s) from symmetry procedure may be beneficial when performing these operations in the setting of cancer treatment
• References
  • Liang Y, Muse-Fisher C, Rambukwella M, Naber SP, Chatterjee A. Malignant and high-risk lesions in the contralateral breast symmetry mastopexy and reduction specimens when performing large-volume displacement oncoplastic surgery. Ann Plast Surg. 2019;82(4S Suppl 3):S185-S191.
  • Sorin T, Fyad JP, Pujo J, Colson T, Bordes V, Leroux A, et al. Incidence of occult contralateral carcinomas of the breast following mastoplasty aimed at symmetrization. Ann Chir Plast Esthet. 2014;59(2):e21-e28.

• Use of oncoplastic surgery has become more common in the surgical treatment of breast cancer
• Multiple studies have compared the surgical complication rates between standard breast-conserving surgery with oncoplastic breast-conserving surgery
• A recent systematic review reported overall low rates of perioperative complications in patients who have undergone oncoplastic breast conserving surgery
• Studies comparing oncoplastic breast-conserving surgery to standard breast-conserving surgery:
  • Have reported:
    • Lower rates of post-operative seroma formation
    • No difference in surgical site infection
    • Lower positive margin and re-excision rates
  • Additional reports have shown this same low risk of perioperative complications in the obese population:
    • Making oncoplastic surgery an option even in obese women
• References
  • Carter SA, Lyons GR, Kuerer HM, Bassett RL Jr, Oates S, Thompson A, et al. Operative and oncologic outcomes in 9861 patients with operable breast cancer: single-institution analysis of breast conservation with oncoplastic reconstruction. Ann Surg Oncol. 2016;23(10):3190-3198.
  • De La Cruz L, Blankenship SA, Chatterjee A, Geha R, Nocera N, Czerniecki BJ, et al. Outcomes after oncoplastic breast-conserving surgery in breast cancer patients: a systematic literature review. Ann Surg Oncol. 2016;23(10):3247-3258.
  • Tong WM, Baumann DP, Villa MT, Mittendorf EA, Liu J, Robb GL, et al. Obese women experience fewer complications after oncoplastic breast repair following partial mastectomy than after immediate total breast reconstruction. Plast Reconstr Surg. 2016;137(3):777-791

• Diagnosis of a breast cancer during pregnancy requires a complex treatment plan with multiple multidisciplinary providers:
  • From both oncology and obstetrics:
    • Coordinating the timing of cancer treatment and the delivery of a high-risk pregnancy
• Gestational or pregnancy-associated breast cancer:
  • Refers to any breast cancer diagnosed:
    • During pregnancy or within the first year after childbirth
  • This is a rare diagnosis:
    • Yet remains the most common cancer in pregnant women:
      • Affecting approximately 15 to 35 per 100,000 deliveries:
        • Approximately 0.05%
• The majority of pregnancy-associated breast cancers are:
  • Ductal in origin, more likely to be poorly-differentiated, ER negative, PR negative and HER2-positive:
    • Compared to non-pregnant women, and present at advanced stages
• Evaluation of a dominant breast mass should include:
  • Ultrasound and mammogram with fetal shielding, and core biopsy
• Interpretation of mammography can be difficult in the highly dense tissue of pregnant women
• Use of MRI during pregnancy is both contraindicated and unhelpful:
  • Gadolinium contrast may cause fetal harm during the first trimester and is typically avoided
• Although the majority (approximately 80%) of breast biopsies in pregnant women will be benign:
  • It is critical that malignancy be ruled out
• Fine needle aspiration during pregnancy is associated with a higher rate of false positive and false negative results, without receipt of tumor markers:
  • Therefore core biopsy is recommended
• Staging should be performed in women with advanced disease, and in those with symptoms concerning for metastases:
  • This should include chest radiograph with fetal shielding, liver ultrasound or MRI without contrast, and “low-dose” radionuclide bone scans
• When possible, treatment of pregnancy-associated breast cancers:
  • Should follow similar guidelines to non-pregnant patients, and if at all possible, the pregnancy should be carried to term
• Systemic treatment of breast cancer during pregnancy involves special consideration of both the mother and baby
• Surgery is safe at all stages
• Chemotherapy:
  • Can be delivered from 14 weeks of gestation following completion of organogenesis through 35 weeks:
    • When it should be stopped to avoid leukopenia in preparation for delivery
  • Data from a single-institution prospective study indicates that:
    • FAC chemotherapy (5-FU, doxorubicin, and cyclophosphamide) is safe during the second and third trimesters
      • With fetal malformations approximating 1%
    • Experience with taxanes remained limited, but National Comprehensive Cancer Network (NCCN) guidelines:
      • Recommend weekly paclitaxel if warranted
    • Methotrexates:
      • Are contraindicated due to teratogenic side effects
    • Although 20% of pregnancy-associated breast cancers are HER2-positive:
      • Anti-HER2 therapy including trastuzumab has not been proven safe during pregnancy and is best delivered in the adjuvant setting:
        • MotHER a prospective U.S. registry, is evaluating women exposed to trastuzumab +/- pertuzumab during pregnancy or within 6 months of conception and following pregnancy outcomes and infants for the first month of life
      • Current recommendations suggest that targeted anti-HER2 therapy be delayed until after delivery
• Breast conservation:
  • Is not recommended if radiation would be timed during pregnancy because this is contraindicated:
    • However, it can be performed if radiation falls after delivery
• Axillary lymph node dissection was previously recommended:
  • But sentinel lymph node biopsy is feasible and should be offered
• Hormone therapy should be postponed until after childbirth
• Chemotherapy during pregnancy can cause concerns for the fetus which depend on the timing of drug administration:
  • Congenital malformations can occur in the first trimester
  • In the second and third trimesters prematurity, low birth weight and myelosuppression are the greatest concerns
• Among approved chemotherapy agents, long-term outcomes of children with in-utero exposure demonstrate normal development, cognition, and school performance when prematurity is controlled for
• References
  • Macdonald HR Pregnancy associated breast cancer. Breast J. 2020 Jan 14. doi: 10.1111/tbj.13714. [Epub ahead of print]
  • Goidescu I, Nemeti G, Caracostea G, Eniu DT, Chiorean A, Pintican R, Cruciat G, Muresan D. The role of imaging techniques in the diagnosis, staging and choice of therapeutic conduct in pregnancy associated breast cancer. Med Ultrason. 2019 Aug 31;21(3):336-343. doi: 10.11152/mu-1958. Review.
  • Alfasi A, et al. Breast Cancer During Pregnancy- Current Paradigms, Paths to Explore. Cancers. 2019; 11: 1669
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Breast Cancer. Available with login at: https://subscriptions.nccn.org.
  • Gooch JC1,2, Chun J1, Kaplowitz E1, Guth A1, Axelrod D1, Shapiro R1, Roses D1, Schnabel F1. Pregnancy-associated breast cancer in a contemporary cohort of newly diagnosed women Breast J. 2019 Aug 25. doi: 10.1111/tbj.13510. [Epub ahead of print]