Mastectomy Flap Necrosis – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This study (full reference below) comes out of Memorial Sloan-Kettering Cancer Center.  Flap necrosis following mastectomy and reconstruction using a tissue expander has always concerned me.  I will never (due to the size of my practice) have the numbers they have or experience.  They state their purpose as

The purpose of this study was to assess the outcomes of our approach to mastectomy flap necrosis and to establish an algorithm that may be useful to other surgeons faced with this complication.

They were able to use the “prospectively maintained database” of all patients treated at Memorial Sloan-Kettering Cancer Center to identify patients with documented mastectomy flap necrosis following immediate tissue expander placement between January of 1995 and March of 2008.  A total of 178 patients were identified (4.3% of 4158 pts who had immediate tissue expander placement).

Of these 178, 29 patients (16%) had a history of prior irradiation. Twenty-five patients (14%) had a history of neoadjuvant chemotherapy, and 68 patients (38%) received adjuvant chemotherapy during expansion or after excision. 

Most healed with local wound care, but 58 (33% of 178) needed surgical excision of the eschar once the flap necrosis was fully demarcated.   Of these, five patients (9%) had prior irradiation, eight (14%) had prior chemotherapy, and 29 (50%) had chemotherapy during expansion or after excision.

In nine patients (15.5% of the 58 who need surgical excision), extensive mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure. 

I appreciate the authors sharing their treatment algorithm which led to their low incidence of failure.

….a more conservative approach that consists of a period of observation during which time the mastectomy flap necrosis is observed clinically over the initial 2 weeks.

Local wound care such as alcohol or Betadine swabbing may be utilized during these first 2 weeks, particularly to manage partial-thickness wounds to keep the necrotic skin clean and dry.

Expansion continues as the full-thickness demarcation becomes more evident over the next 3 to 4 weeks.

Antibiotics are not routinely administered, other than the typical oral course used for the duration that closed-suction drains remain in the breast pocket. However, if significant erythema surrounding the mastectomy flap necrosis is present and there is a clinical suspicion of infection, a more aggressive strategy using antibiotics and earlier excision may be implemented.

At about 4 to 6 weeks, full-thickness excision and closure are performed, typically in the clinic setting, with sterile removal of expander fluid to allow closure without tension.

Re-expansion is then carried out after closure approximately 2 weeks later

REFERENCE

Salvage of Tissue Expander in the Setting of Mastectomy Flap Necrosis: A 13-Year Experience Using Timed Excision with Continued Expansion; Plastic and Reconstructive Surgery. 124(2):356-363, August 2009; Antony, Anuja K.; Mehrara, Babak M.; McCarthy, Colleen M.; Zhong, Toni; Kropf, Nina; Disa, Joseph J.; Pusic, Andrea; Cordeiro, Peter G.

SurgeXperiences 304 is Up!

Øystein, Sterile Eye, is the host of this edition of SurgeXperiences. You can read the “history” edition here.

Welcome to edition 304 of SurgeXperiences, the one and only biweekly collection of surgery-related blog posts.

The pictures in this edition are all from the US National Museum of Health & Medicine’s collection of public domain photographs, available at Flickr. Click on the pictures for larger versions.

The host of the next edition (305), September 6th, will be              . The deadline for submissions is midnight on Friday, August 21st. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Geverfde Quilt

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I received my quilt from the 3rd ALQS earlier this week.  It arrived from the Netherlands.  The quilt was made by Margreet.  You can read her description of how she made the quilt and see her photos (better than mine) here.

The quilt is 19 in X 19 in.  Margreet forgot to make a label for it, so I added one with her name, country, date, and ALQS3 on it.  The quilt is hanging my front office at work.

You may recall the quilt I did for this swap was Fractures I.  To view the other quilts and see who got which ones go here.

Symmetry in Wool

I finished another shawl! The pattern is “symmetry in silk” from the Shawls and Scarves book. The yarn is Harmony 100% wool, color HC03. It was extra I had from the Estonian Garden Shawl I finished back in February. Sorry if the photos aren’t great, I have not yet learned the best way to take photos to show off lace knitting.

The shawl measures 15 in X 88 in. It is knitted on the bias.


I think I may keep this one for myself.

Nipple Sharing &/or Sparing Breast Surgery

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Two nice articles in the June edition of the Journal of Plastic and Reconstructive Surgery.   Full references are given for both below.

There are many techniques used for nipple reconstruction which should tell you that none is perfect.  One of the main issues is loss of nipple projection over time.  So if it is safe to spare the nipple when doing a mastectomy so no nipple reconstruction is needed – perfect! 

The first article below looks at when it can be safely spared in prophylactic mastectomy (risk-reduction mastectomy) and therapeutic mastectomy clinical scenarios.   Spear and colleagues did a literature review and came to the following conclusion:

It is clear from a review of the literature of the past 15 years that the subject of nipple-sparing mastectomy is complex and evolving. The subject is properly divided into two parts: risk prevention and therapeutic mastectomy.

There now seems little doubt that nipple-sparing mastectomy is an oncologically safe approach to prophylactic mastectomy. For that purpose, proper patient selection and technique remain open questions. ……….

Nipple-sparing mastectomy at the time of therapeutic mastectomy remains more controversial.  There is developing consensus by those interested in nipple-sparing mastectomy as a possibility with therapeutic mastectomy that it is best suited for women who meet certain criteria. …….

The collective data suggest that, using the above  below criteria, the risk of occult tumor in the nipple should be 5 to 15 percent; that frozen section of the base of the nipple will identify many if not most of those occult tumors; and that the risk of occult tumor still being present in patients screened as above with frozen section-negative findings is as low as 4 percent.

The tumor criteria listed include:

• The tumor should be 3 cm in diameter or less
• The tumor should be 2 cm away from center of the nipple
• Clinically negative axillae or sentinel node negative
• No skin involvement, and no inflammatory breast cancer.
• If possible, they should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement.

When the nipple can be spared then there is no need for nipple reconstruction.  When it can’t be, then the nipple sharing technique can be useful.  As with the above, the cancer risk is addressed:

Fears of cancer in the transplanted nipple and concerns for surveillance are thus far unfounded. This occurrence has never been described in the literature. Furthermore, as more liberal use of nipple-sparing mastectomy occurs, a large cohort of patients with retained nipples will be able to be followed over time to see whether we even need to be concerned. For now, simple self-examination as performed by these patients is appropriate.

The article gives a good description of two different ways to perform the nipple sharing depending on the shape of the donor nipple.

Both articles are worth your time to read.



REFERENCES
Nipple-Sparing Mastectomy; Plast & Recontr Surg 123(6):1665-1673, June 2009; Spear, Scott L.; Hannan, Catherine M.; Willey, Shawna C.; Cocilovo, Costanza
Unilateral Nipple Reconstruction with Nipple Sharing: Time for a Second Look; Plast & Reconstr Surg 123(6):1648-1653, June 2009; Zenn, Michael R.; Garofalo, Jo Ann

Related Posts
Breast Reconstruction – Part I
Breast Reconstruction – Part II
Integrating Radiation Therapy & Breast Reconstruction

Weight Lifting Good for Breast Cancer Patients

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Historically, we healthcare providers have cautioned breast cancer patients to avoid weight training after a mastectomy and or axillary dissection.  We often use 15 lbs as a guideline for a save weight to lift using the arm on the mastectomy side.  A new study suggests this advice turns out to be misguided.

The study has been published in the August 13 issue of the New England Journal of Medicine.  It is a small study, but the results do challenge our current reluctance to allow lymphedema patients to weight-lift.

Kathryn Schmitz, PhD, MPH and colleagues enrolled 141  breast cancer survivors with lymphedema.   The enrollees were then placed into two groups.  One was assigned to a weight-lifting group who lifted twice-weekly for 13 weeks.  The other group was used as a control group and did no weight-lifting.

The weight-lifting women (71) wore a custom-fitted compression garment on their affected arm during their workouts.  Their arms were measured monthly to ensure any changes were noted as soon as they occurred.  Each week were asked about changes in symptoms.

Both groups had the same proportion of women who experienced an increase of 5% or more in their limb swelling.  However, the weight-lifting group had fewer exacerbations of their condition which required treatment from a physical therapist; 9 compared to the 19 women in the control group.   The weight-lifting group also had a reduction in symptoms such as pain.

Further studies need to be done to verify their results, but I would allow motivated patients to begin weight-lifting with a slow, progressive program.   They should learn proper technique.  They should wear their custom-fit compression garment during all exercise sessions.

Weight-lifting has been shown to decrease bone loss which is important in these women as in all women.  Having more strength can also aid in everyday activities like carrying bags of groceries or carrying children/grandchildren.

REFERENCE

Weight Lifting in Women with Breast-Cancer–Related Lymphedema; New England Journal Medicine, Vol 361 (7):664-673, August 13, 2009; Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed., Catherine T. Williams-Smith, B.S., and Quincy P. Greene

Related Posts

Lymphedema (December 5, 2007)

ARM Technique (October 15, 2008)

Shout Outs

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Invisible Illness Week is this week's host of Grand Rounds. You can read it here (photo credit).  It’s the “back to school” edition.

It’s Back to School time and also coming up is National Invisible Chronic Illness Awareness Week, September 14-20. 2009. About 133 million people, nearly 1 in 2 in the USA live with a chronic condition and most of these are not visible. We hope you will join us for our virtual conference with 20 online free seminars for Invisible Illness Week (9/14-9/28).

This week the Grand Rounds Carnival takes a “look” (ironic choice of words) at invisible illness issues as well as the best of the medical bloggers who update us on everything from new medical gadgets to their personal experiences.

I know Laikas’ post is part of Grand Rounds, but want to highlight it here.  Her post is on her “invisible illness” Addison's disease.

I won’t write about this professionally -being a librarian-, but I will speak from my own experience.

As many of you know, I’ve the chronic illness Addison’s Disease. Not that I feel ill. It doesn’t affect me, really… Not anymore.. I think.

Dr Val wants to invite you all the the less expensive version of TEDMED – BIL:PIL. 

….. so some creative young folks decided to create a free sister conference at the same venue. They called it “BIL:PIL” as a kind of riff on Bill & Ted’s Excellent Adventure, and keeping “PIL” for a rhyming medical theme. Pretty funny.

…… has lured me into presenting at BIL:PIL. I’ll be joined by some speakers from TEDMED and a gaggle of social media and medical technology innovators. In fact, it’s not too late to register or vote for your favorite speaker at BIL:PIL as programming will not be finalized until September 30th.

The meeting will be held October 30th and 31st at the San Diego State University BioScience Center in San Diego, California.

Interesting segment on NPR regarding health co-ops,  What Health Care Co-Ops Might Look Like.  You can hear it here.   A companion piece, “Health Co-Ops Explained” by Scott Hensley, is also worth reading.

Dr Rob has made his local paper, “Doctor 's humor is a hit on iTunes!"  Check out his podcast,  “House Call Doctor.” You can find the list of his podcasts here.  Enjoy!

Crazy for Quilts Contest Gallery is up!  The quilt I did is #4.  

All contest quilts will be auctioned via eBay. All proceeds will support AAQ. All auctions begin and end at 9:00 PM Eastern

On eBay search keyword "Alliance for American Quilts." Never used eBay? No problem! View a great tutorial on the eBay website.

                            

This week Dr Anonymous guest will be Dr. Rob talking about his House Call Doctor podcasts.  Come joint us.  The show starts at 9 pm EST.

Upcoming Dr. A Shows 

8/27: Dr. A Show 2nd Anniversary & BlogWorldExpo
9/3 : Dr. A Show (9:30pmET)

Should Excised Mastectomy Scars Be Routinely Sent for Analysis?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Surgeons are commonly faced with the question of whether or not a surgical specimen should be submitted for histologic analysis. Routine histologic examination of clinically unsuspected mastectomy scars that are excised during secondary corrective surgery is considered good practice, but in this era of cost containment in medicine should it be done? 

Locoregional recurrence of breast cancer following mastectomy occurs mainly in the first 3 to 5 years at an incidence rate of  3 to 7%.    That risk after breast-conserving therapy is 1.5 to 2 % per year, stabilizing around 10 to 20 % at 10 to 15 years. 

The first reference article below involved a retrospective review of 433 patients with a history of breast cancer whose mastectomy or breast-conserving surgery scars (455 scars, 22 pts had bilateral surgery) were excised and sent for histopathologic examination.   This included all their patients who had delayed breast reconstruction between January of 2000 and December of 2006 at the three National Health Service plastic and reconstructive surgery units in the West Midlands, United Kingdom.   Four (o.9% of 455) of the mastectomy scars (only three patients as one had bilateral scar recurrence) were positive for carcinoma recurrence.    None of the patients had any preoperative clinical suspicion of recurrent disease.  Their patients mean interval from primary breast surgery to reconstruction was 46.8 months (range, 2 months to 32 years).

This studies authors concluded:

In keeping with cancer surgery principles and with the potential for improved patient outcome, we recommend routine histologic examination of mastectomy scars at the time of delayed breast reconstruction.

The second reference article had a similar number of patients (424) treated by plastic surgeons of The Netherlands Cancer Institute from January of 1994 through May of 2004.   They sent 728 scars for routine histologic examination, 503 (70 percent) of which were excised within the first 3 postmastectomy years.  None of the patients had any preoperative clinical suspicion of recurrent disease.  Several patients (210 of 424) had multiple scars excised.  No evidence of metastatic or de novo tumor was found in any of the 728 scars, but residual glandular tissue was found in 11 scars. 

This studies authors concluded:

Because we found no evidence of tumor in any of the 728 scars we, more convincingly, support and extend their conclusion that routine submission of clinically unsuspected scars excised at the time of breast reconstruction or scar correction after prophylactic or curative breast surgery did not benefit our patients.

Which is the correct answer?  I honestly don’t know.  For now, I’ll continue to routinely send any postmastectomy scars.

REFERENCES

Mastectomy Scars following Breast Reconstruction: Should Routine Histologic Analysis Be Performed?; Plast Reconstr Surg. 123(4):1141-1147, April 2009; Warner, Robert M.; Wallace, David L.; Ferran, Nicholas A.; Erel, Ertan; Park, Alan J.; Prinsloo, Daniel J.; Waters, Ruth

Routine histologic examination of 728 mastectomy scars: Did it benefit our patients?;  Plast Reconstr Surg. 2006;118:1288-1292; Woerdeman LA, Kortmann JB, Hage JJ.
Locoregionally recurrent breast cancer: Incidence, risk factors and survival;  Cancer Treat Rev. 2001;27:67-82; Clemons M, Danson S, Hamilton T, Goss P.

SurgeXperiences 304 – Call for Submissions

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

SurgeXperiences 304 (August 23rd)  will be hosted by Øystein at Sterile Eye.   His suggested theme is “History.”  The deadline for submissions is midnight on Friday, August 21st.  Be sure to submit your post via this form. 

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.   If you would like to be the host  in the future, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Here is a list of some of my past posts with a surgical history
Dr. Joseph Murray, Plastic Surgeon & Scientist (Sept 1, 2007)
Paul Brand, MD (1914-2003)  (November 7, 2007)
DeBakey and Cooley (November 27, 2007)
Spare Parts (December 10, 2007)
Dermatomes (May 7, 2008)
The Blalock-Taussig-Thomas Collaboration (July 23, 2008)
How Poland’s Syndrome Was Named (June 25, 2009)

Shirley's Arbor Windows

I made this quilt for one of the circulating nurses I work with at the surgery center.  She asked for greens and mauves.  I found all the “center” fabrics in my stash and decided use them.  I liked the way it looked as I lay it out, but now I wish I had mingled the pinks into the green rather than concentrating them in the center.  Still, I like the quilt and more importantly Shirley does.

The quilt uses a pattern called “arbor windows.”  It is machine pieced and quilted.  It is 46 in X 63 in.

Here is a close photo to show some of the fabrics.  I used eight different pink/mauves.  I used three different greens.
This near photo shows the backing fabric that I had initially intended to use for the border, but I like the green border better. 

ASPS Task Force Updates Position on Fat Grafting

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I have written about fat grafting to the breast previously here and here. 

The Fat Graft Task Force of the American Society of Plastic Surgeons (ASPS) convened to try to answer the question of whether fat grafting compromises breast cancer detection and/or results in potentially catastrophic sequelae in patients?  Their conclusion:  there is no indication that fat grafting is an unsafe procedure with qualifications that more research is needed.

Sydney R Coleman, MD is quoted in the Cosmetic Surgery Times article, "In review of the multitude of evidence-based results of clinical trials, case series and reports, the Task Force found that there is no evidence that indicates that fat grafting is an unsafe procedure.  Nevertheless, the report did say that in order for the Task Force to make concrete recommendations for or against fat grafting for specific applications, high-quality randomized controlled trials would be needed to further evaluate safety and efficacy."

The following conclusions are from the February 2009 Task Force Report:

CONCLUSIONS
Clinical Applications
Based on a review of the current literature and a lack of strong data, the Task Force cannot make specific recommendations for the clinical use of fat grafts. Although fat grafts may be considered for use in the breast and other sites, the specific techniques of graft harvesting, preparation, and injection are not standardized. The results therefore may vary depending on the surgeon’s technique and experience with the procedure. Although there are little data to provide evidence for long-term safety and efficacy of fat grafting, the reported complications suggest that there are associated risks. Regarding fat grafting to the breast, there are no reports suggesting an increased risk of malignancy associated with fat grafting. There is a potential risk of fat grafts interfering with breast physical examination or breast cancer detection; however, the limited data available suggests that fat grafts may not interfere with radiologic imaging in detecting breast cancer.

Future Research
The Task Force believes autologous fat grafting is a promising and clinically relevant research topic. The current fat grafting literature is limited primarily to case studies, leaving a tremendous need for high-quality clinical studies. While this evidence-based review resulted in few, if any, new data that would prompt a substantial change in the current state of fat grafting, the lack of new information poses two important questions: (1) are current methods of fat grafting still the "gold standard," or (2) is more research needed and should funding be directed toward new studies? For many aspects of fat grafting, the Task Force found the latter to be true and has
suggested the following areas for future research:

• Randomized controlled trials to assess safety and efficacy of fat grafting for different indications
• Randomized controlled trials to assess safety and efficacy of specific fat grafting techniques
• Studies to further assess the effect of fat grafting on breast cancer detection and treatment.
• Studies to identify risk factors and improve patient selection for procedures involving fat grafting.
• Studies to investigate aspects of cell/tissue viability and graft survival, as well as long term storage and banking of fat grafts.
    

REFERENCES
ASPS' Fat Graft Task Force updates position on safety of autologous fat grafting; Cosmetic Surgery Times, Aug 1, 2009; Ilya Petrou, MD
Current Applications and Safety of Autologous Fat Grafts: A Report (pdf); American Society of Plastic Surgeons; Feb 2009
Fat Transfer/Fat Graft and Fat Injection:  ASPS Guiding Principles (pdf); January 2009


Related Posts

Fat Injections for Breast Augmentation (November 6, 2008)
Complications After Autologous Fat Injections to the Breast – an Article Review (April 2, 2009)
Recent NPR Stories on Plastic Surgery (June 3, 2009)

Internal US Technique Treats Hyperhidrosis—an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This was suppose to simply be an article review. I was intrigued by the potential of using ultrasound (US) to damage the sweat glands when I read this article in the August issue of Cosmetic Surgery Times. I even went back and read the Aesthetic Plastic Surgery Journal article referenced, but I have gotten sidetracked by this photo. It troubles me.

See how it is labeled an intra-operative photo? Notice the surgeon is wearing what appears to be a large jeweled ring under her sterile glove. Who wears jewelry in the OR??? That’s not proper sterile technique!

Intra-operative photo shows application of internal ultrasound therapy to damage the sweat glands. (Photo credit: Sharon Giese, M.D., F.A.C.S.)

In the article Dr. Giese states the procedure uses the heat energy of the ultrasound liposuction to “presumably kills the sebaceous glands. Permanently." No biopsies done to know for sure. No starch– iodine testing to quantify the decrease in sweat.

Dr Giese reports good results with her patients, but doesn’t quantify the number of patients. She reports that all the women no longer need deodorant. She reports that one male has had 65% reduction in sweating which can now be controlled by deodorant.

In looking further into the technique I found two more recent articles (the 3rd and 4th below).

In the 4th article, the researchers had 13 patients (3 males, 10 females) with significant axillary hyperhidrosis which they treated with the VASER ultrasound and followed for 6 months. Eleven of 13 patients had significant reduction in sweat/odor with no recurrence of significant symptoms at 6 months. Two patients had a reduction in sweat/odor but not to the degree they desired. No significant complications were noted. They report the complete procedure takes less than 1 h to treat two axillae using local anesthetic.   Once again, no objective measures of sweating.

I remain intrigued with this procedure, but would love more scientific measures and studies.  Still, I suppose the patients only care about the subjective measures when it comes to sweating.

REFERENCES
Internal ultrasound technique treats hyperhidrosis; Cosmetic Surgery Times, Aug 1, 2009; Donley-Hayes, Karen

Very Superficial Ultrasound-assisted Lipoplasty for the Treatment of Axillary Osmidrosis; Aesthetic Plast Surg. 2000 Jul-Aug;24:275-279; Park S

Characteristics of Refractory Sweating Areas Following Minimally Invasive Surgery for Axillary Hyperhidrosis; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; Falk Georges Bechara, Michael Sand and Peter Altmeyer

Treatment of Axillary Hyperhidrosis/Bromidrosis Using VASER Ultrasound; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; George W. Commons and Angeline F. Lim