Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

OBJECTIVE: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. BACKGROUND: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. METHODS: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. RESULTS: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. CONCLUSION: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG

The effect of lymphatic microsurgical preventive healing approach (LYMPHA) on the development of upper-extremity lymphedema following axillary lymph node dissection in breast cancer patients

Background/Objective: Lymphedema following axillary lymph node dissection (ALND) is a common complication that can negatively impact quality of life as it reduces the functional capacity of the affected arm. It can also predispose patients to serious infectious complications such as limb cellulitis and development of malignancy. The lymphatic microsurgical preventive healing approach (LYMPHA procedure) involves the creation of a lymphatic‐to‐venous bypass at the time of axillary lymph node dissection (ALND) as a means of preventing lymphedema. The goal of our study is to assess the effect of LYMPHA on the development of clinical and subjective post‐operative lymphedema. Methods: This is a prospective longitudinal study in patients with breast cancer who underwent ALND with or without LYMPHA. The incidence of lymphedema was compared between ALND alone and ALND with LYMPHA using descriptive statistics. Limb circumference of both affected and unaffected limbs were measured and used to calculate limb volume by using an equation that converts limb circumference (cm) to volume (cc). Lymphedema was defined as a volume difference of ≥10% between the affected and unaffected limb. Patient symptoms were also assessed and compared between the 2 groups. Patient demographics including age, preoperative body mass index (BMI), smoking history, comorbidities, receipt of neoadjuvant or adjuvant chemotherapy, and receipt of adjuvant radiation were compared between the groups. Results: In our cohort of 139 patients, 104 underwent ALND with LYMPHA, while 35 underwent ALND alone. Of these, 52.5% of patients had documented interlimb circumference measurements. The mean age was 52.6 years old, mean BMI was 30.16 kg/m2, 4 patients (2.9%) had pre‐operative radiation, 102 patients (73.4 %) had post‐operative radiation, 86 patients (61.9 %) had neoadjuvant chemotherapy, 41 and 58 patients (41.7 %) had adjuvant chemotherapy. There were no significant differences between the 2 groups in the above demographics and treatment variables, except those who underwent ALND alone had a significantly higher incidence of diabetes mellitus (25.7% patients with ALND alone vs 11.5% LYMPHA patients (p=0.043)). Based on patient reported symptoms and the need to initiate complete decongestive therapy, 57.1% (n=20) of patients who underwent ALND alone developed lymphedema compared to 26.9% (n=28 patients) of those who had ALND with LYMPHA (p=0.0011). When comparing the relative volume difference, 57.1% (n=8) of ALND alone patients developed lymphedema versus 20.3% (n=12) of LYMPHA patients (p=0.0055). Conclusions: Our data support the universal use of LYMPHA at the time of ALND as a means of preventing upper extremity lymphedema. Further studies are needed to evaluate quality of life and functional differences between those who had LYMPHA and those who did not

Oncoplastic Breast Consortium consensus conference on nipple-sparing mastectomy.

Purpose Indications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion. Methods The panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology. Results Consensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference. Conclusions In case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques