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Modern treatment of complex midfacial defects has evolved over the past 5 years, primarily with the advent of reliable vascularized bone flaps and osseointegrated implants. To determine the effectiveness of these advances, 26 consecutive patients with complex midfacial defects treated from 1991 through 1995 with immediate muscle-flap coverage were evaluated. The etiology of the defect included neoplasm (n = 23) and trauma (n = 3). Seventy-eight percent of the patients received adjuvant radiation therapy. Follow-up ranged from 3 months to 4 years, with a mean of 18 months. Twenty-three patients (88 percent) were reconstructed with a single major procedure. All patients had free-flap reconstruction, and 100 percent of the flaps survived. Late tumor recurrence was seen in 5 of 23 patients (22 percent) and was detected promptly. Aesthetic and functional results were rated good or excellent in 77 and 88 percent of the patients, respectively, as determined by patient questionnaires and physical examinations. Fourteen of 18 patients (78 percent) undergoing partial or complete alveolar ridge resection received dental rehabilitation, 43 percent of whom received osseointegrated implants into either a bone flap or remaining native bone. Osseointegrated implants were inset during the initial reconstruction 50 percent of the time. A treatment algorithm for free-flap selection based on the size of the defect and the bony requirement for reconstruction is presented. Bony restoration is only required in those areas where osseointegrated implants need to be placed. In such cases, the fibula osteocutaneous free flap is the flap of choice. Otherwise, soft-tissue flaps are selected based on wound size. Immediate free-flap coverage provides effective, single-stage treatment, both aesthetically and functionally, for complex midfacial defects.

Background: Among women with unilateral cancer, rates of contralateral prophylactic mastectomy (CPM) are continuing to increase. However, little is known about whether rates and types of complications differ between patients undergoing unilateral mastectomy or bilateral mastectomy, limiting the surgical outcomes evidence that can be presented in pre-surgical decision making for women considering CPM. This study was undertaken to determine whether surgical complications are increased in women undergoing CPM compared to those without CPM. Methods: Between the years 2005–2010, all patients at UCSF undergoing mastectomy with immediate reconstruction were entered into a prospective database. This database was queried for patients with unilateral cancer who had mastectomy and immediate reconstruction with or without CPM. Surgical outcomes, including implant loss, admission for IV antibiotics, and return to OR were evaluated and compared between patients who did and did not undergo CPM. Patients with bilateral cancer or bilateral prophylactic surgery were excluded; analyses were limited to patients with a minimum of 1 year follow-up. Results: 468 patients were identified who met study criteria, totaling 667 breasts. Mean follow-up time was 22 months (range 12 - 69 months). 269 of the 468 (57.5%) patients had unilateral mastectomy only, while 199 of 468 (42.5%) patients also had CPM. There were no differences in tumor grade, stage, follow-up time, smoking history, or radiation (prior or post-surgery) between the two groups. The only significant differences between the unilateral and bilateral groups were median age at diagnosis (50.7 vs. 45.9 respectively; p < .0001) and receipt of neoadjuvant chemotherapy (34.7% vs. 41.3% respectively; p < .01). Surgical outcomes were compared between groups. The overall rate of major complications differed significantly due to an increased rate of infectious complications and unplanned return to surgery in the CPM group (Table 1). Nevertheless, this did not result in a higher implant loss rate in the CPM group. In patients undergoing bilateral mastectomy, overall complication rates were comparable between the index breast and the CPM breast; however, there was a higher implant loss rate in the index breast (22/177 vs. 11/188; p=0.05). Conclusions: While CPM is an increasingly common procedure, it is associated with an increased risk of major post-operative surgical complications. In this cohort, patients undergoing bilateral mastectomy for unilateral cancer had higher rates of overall complications, greater use of IV antibiotics, and more frequent return to the operating room. Since the majority of CPM cases are not at sufficiently high risk for a second breast cancer to meet clinical criteria for prophylactic surgery, guidelines and clinical recommendations should consider these increased complication rates when counseling women contemplating CPM. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD02-01.

INTRODUCTION: Total skin-sparing mastectomy (TSSM) is increasingly offered to women for both therapeutic and prophylactic indications. When combined with immediate breast reconstruction, patients can achieve excellent aesthetic results and high satisfaction. However, the oncologic safety of the procedure remains controversial. Further, the technique can be associated with higher rates of postoperative ischemic complications. We conducted this study to determine oncologic and ischemic outcomes in a large cohort of patients undergoing TSSM and immediate reconstruction. METHODS: Patient and tumor characteristics and treatment details were collected in a prospectively maintained database. All patients undergoing TSSM and immediate breast reconstruction at our institution from 2001 to 2010 were included in the analysis. The development of any post-operative complications or local or distant recurrence was determined. RESULTS: TSSM with immediate reconstruction was performed in 428 patients for a total of 657 breasts. Mean patient age was 46.9 years. 210 patients (49%) had neoadjuvant chemotherapy for locally advanced disease. 114 patients (26.7%) had post-mastectomy radiation therapy. 54% of patients had bilateral mastectomies. Prophylactic mastectomies (either unilateral or bilateral) accounted for 244 (37.1%) of cases, which included bilateral mastectomies in 15 patients (30 cases) who were known BRCA-1 or -2 mutation carriers. Expander-implant reconstruction was performed in 80% of the cases, while the rest of the cases involved autologous reconstruction (15.3%) or immediate implant placement (4.7%). On pathologic examination, nipple tissue from 11 breasts (1.7%) contained in situ cancer and from 9 breasts (1.4%) contained invasive cancer; re-excision was performed in 7 of these cases, the nipple-areolar complex was removed entirely in 9 cases, and radiation therapy was given without further excision in the rest of cases. Ischemic or necrotic post-operative complications included 13 cases (1.9%) of partial nipple loss, 10 cases (1.5%) of complete nipple loss, and 78 cases (11.8%) of skin flap necrosis or incisional dehiscence. At a median follow-up of 23 months (range 3–116 months), 5 patients (1.2%) had developed a local recurrence alone, 10 patients (2.4%) had developed a distant recurrence alone, and 6 patients (1.4%) had developed both loco-regional recurrence and distant metastases. In the subset of patients with at least 3 years’ follow-up, rates of local and of distant recurrence were 1.7% at a median of 45 months follow-up. None of the patients who underwent bilateral prophylactic mastectomy for BRCA-1 or -2 mutations developed subsequent breast cancers. CONCLUSIONS: In this large, high-risk cohort, TSSM was associated with low rates of nipple involvement and loco-regional recurrence. Ischemic complications, although uncommon, often resulted in nipple loss. These short-term outcomes are encouraging, although longer follow-up will be important for confirmation of long-term oncologic safety. Serial improvements in surgical technique can improve selection criteria and reduce post-operative complication rates. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD02-06.