Post-Mastectomy Breast Reconstruction Disparities: A Systematic Review of Sociodemographic and Economic Barriers

Background: Breast reconstruction (BR) following mastectomy is a well-established beneficial medical intervention for patient physical and psychological well-being. Previous studies have emphasized BR as the gold standard of care for breast cancer patients requiring surgery. Multiple policies have improved BR access, but there remain social, economic, and geographical barriers to receiving reconstruction. Threats to equitable healthcare for all breast cancer patients in America persist despite growing awareness and efforts to negate these disparities. While race/ethnicity has been correlated with differences in BR rates and outcomes, ongoing research outlines a multitude of issues underlying this variance. Understanding the current and continuous barriers will help to address and overcome gaps in access. Methods: A systematic review assessing three reference databases (PubMed, Web of Science, and Ovid Medline) was carried out in accordance with PRISMA 2020 guidelines. A keyword search was conducted on 3 February 2024, specifying results between 2004 and 2024. Studies were included based on content, peer-reviewed status, and publication type. Two independent reviewers screened results based on title/abstract appropriateness and relevance. Data were extracted, cached in an online reference collection, and input into a cloud-based database for analysis. Results: In total, 1756 references were populated from all databases (PubMed = 829, Ovid Medline = 594, and Web of Science = 333), and 461 duplicate records were removed, along with 1147 results deemed ineligible by study criteria. Then, 45 international or non-English results were excluded. The screening sample consisted of 103 publications. After screening, the systematic review produced 70 studies with satisfactory relevance to our study focus. Conclusions: Federal mandates have improved access to women undergoing postmastectomy BR, particularly for younger, White, privately insured, urban-located patients. Recently published studies had a stronger focus on disparities, particularly among races, and show continued disadvantages for minorities, lower-income, rural-community, and public insurance payers. The research remains limited beyond commonly reported metrics of disparity and lacks examination of additional contributing factors. Future investigations should elucidate the effect of these factors and propose measures to eliminate barriers to access to BR for all patients

Comprehensive multimodal surgical treatment of end‐stage lower extremity lymphedema with toe management. The combined Charles,’ Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures

Background: End‐stage lower extremity lymphedema (LEL) poses a particularly formidable challenge to surgeons as multiple pathological processes are at work. Because single modality treatment is often unsuccessful, we devised a comprehensive multimodal surgical treatment. The aim of this study is to share the technical considerations and examine the clinical outcomes of this combined approach. Methods: Between 2013 and 2017, patients with International Society of Lymphology stage III, who underwent the combination treatment of Charles,’ Homan’s procedure with toe management and vascularized lymph node transfer (CHAHOVA), were included in this retrospective study. Outcomes evaluated were limb size, number of infectious episodes, compression garment usage, and rate of complications. Results: A total of 68 patients were included. With a mean follow‐up of 29 months, the overall circumference reduction rate for the upper thigh and the rest of the extremity was 67.4% (48.2‐88.2%) and 98.1% (88‐100%), respectively. During the follow‐ups, 2 (2.9%) patients experienced episodes of cellulitis and the average number of yearly infections decreased from 4.2 to 1.2 episodes per person. All patients were able to discontinue compression therapy without recurrence of lymphedema. Nine (13.2%) patients reported minor complications. Conclusion: The combine CHAHOVA in a single‐stage procedure is an effective and safe approach in the end‐stage LE

The radial forearm free flap as a â\u80\u9cvascular bridgeâ\u80\u9c for secondary microsurgical head and neck reconstruction in a vessel-depleted neck

BACKGROUND: In a vessel-depleted neck, distant recipient sites may be the only option for secondary free flap reconstruction. While interposition vein grafts and arteriovenous loops can bridge the gap between the recipient and donor pedicle, they are not without risks. In these scenarios, we examinate the reliablity of a radial forearm free flap (RFFF) as an alternative vascular conduit. PATIENTS AND METHODS: A retrospective review of cases between March 2005 and May 2016 was performed. Demographic data, prior surgical history, intraoperative details and outcomes were recorded. A total of ten patients, eight male and two female, with a mean age of 54.2 years (range, 39-74) were identified. The RFFF was initially anastomosed to either the thoracoacromial (n = 6) or internal mammary vessels (n = 4) and subsequently served as the recipient pedicle for the second "main" flap, an anterolateral thigh (n = 4), jejunum (n = 3) or fibula flap (n = 3). RESULTS: The average RFFF dimensions were 13.8 cm by 5.8 cm. All twenty flaps, ten RFFF and ten "main' flaps survived completely with only one case of minimal epidermal loss. One patient with esophageal reconstruction with jejunum developed a fistula that required closure with a local falp. At a mean follow-up of 18.4 months (range 8-29), the reconstructive goals had been achieved in all cases. CONCLUSIONS: The RFFF serves as a reliable "vascular bridge" that extends the reach of distant recipient sites to free flaps in secondary head and neck reconstruction

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck

Background:Reconstruction in a vessel-depleted neck is challenging. The success rates can bemarkedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reli-able flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to beexplored. The aim of this report is to present our experience and clinical outcomes using the retro-grade flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflowfor complex head and neck reconstruction in patients with a vessel-depleted neck.Methods:Between July 2010 and June 2016, nine patients with a vessel-depleted neck under-went secondary head and neck reconstruction using the retrograde TCA as recipient vessel formicroanastomosis. The mean age was 49.6 years (range, 36 to 68 years). All patients had previousbilateral neck dissections and all, except one, had also received radiotherapy. Indications includedneck contracture release (n53), oral (n51), mandibular (n53) and pharyngoesophageal (n52)reconstruction necessitating free anterolateral thigh (n53) and medial sural artery (n51) perfora-tor flaps, fibula (n53) and ileocolon (n52) flaps respectively.Results:There was 100% flap survival rate with no re-exploration or any partial flap loss. Onecase of intra-operative arterial vasospasm at the anastomotic suture line was managed intra-operatively with vein graft interposition. There were no other complications or donor site morbid-ity during the follow-up period.Conclusions:In a vessel-depleted neck, the reverse flow of the TCA may be a reliable option forcomplex secondary head and neck reconstruction in selected patients

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel‐depleted neck

Background:Reconstruction in a vessel-depleted neck is challenging. The success rates can bemarkedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reli-able flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to beexplored. The aim of this report is to present our experience and clinical outcomes using the retro-grade flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflowfor complex head and neck reconstruction in patients with a vessel-depleted neck.Methods:Between July 2010 and June 2016, nine patients with a vessel-depleted neck under-went secondary head and neck reconstruction using the retrograde TCA as recipient vessel formicroanastomosis. The mean age was 49.6 years (range, 36 to 68 years). All patients had previousbilateral neck dissections and all, except one, had also received radiotherapy. Indications includedneck contracture release (n53), oral (n51), mandibular (n53) and pharyngoesophageal (n52)reconstruction necessitating free anterolateral thigh (n53) and medial sural artery (n51) perfora-tor flaps, fibula (n53) and ileocolon (n52) flaps respectively.Results:There was 100% flap survival rate with no re-exploration or any partial flap loss. Onecase of intra-operative arterial vasospasm at the anastomotic suture line was managed intra-operatively with vein graft interposition. There were no other complications or donor site morbid-ity during the follow-up period.Conclusions:In a vessel-depleted neck, the reverse flow of the TCA may be a reliable option forcomplex secondary head and neck reconstruction in selected patients