Considerations for performing immediate breast reconstruction during the COVID‐19 pandemic

Abstract

The appearance of coronavirus disease 2019 (COVID-19) has provoked a global public health emergency, spreading to more than 150 countries, 1 and Italy has been particularly affected.The COVID-19 pandemic has represented a contemporary "sui generis" challenge for healthy system requiring a sudden reorganization of hospital structures and resettlement of therapeutic algorithms. The directives of the Italian Ministry of Health indicated to postpone all nonurgent surgical procedures and outpatient services, performing only urgent interventions or procedures for oncological pathologies. On March, the American College of Surgeons published guidelines for triage of nonemergent surgical intervention during the coronavirus pandemic, based on the Elective Surgery Acuity Scale (ESAS). 2 The ESAS considers lowrisk cancer as tier 2a (deferrable whenever possible) and other cancers as tier 3 a and so not deferrable. 2 Cancer patients have an elevated risk for acquiring COVID-19 and subsequent complications because of their immunodepression, poor functional status, and frequent hospital visits and admissions. 3 Moreover, Liang et al reported that oncologic patients who underwent surgery in the 30 days before contracting COVID-19 in China developed more frequently a severe form of disease compared to those who did not underwent surgery. 4 Breast carcinoma is the most frequent malignancy among women, and its modern surgical treatment nowadays includes breast reconstruction. Given the rapid evolution of the current situation, very few data of the different breast units about the present attitude toward breast cancer management are available. 5 Breast surgeons seem to agree on the fact that delaying elective surgical procedures may be more appropriate for select cases such as clinical stage I or stage II in which 60-day delays in surgical intervention were not associated with worse oncological outcomes. 6,7 To date, no guidelines on breast reconstructive surgery have been published. The aim of this article is to report our decision-making attitude during COVID-19 emergency in the field of breast reconstruction. In line with government directives, our institution limits elective surgery to oncologic procedures, and the reconstructive time is considered an integrated part of the treatment. All admitted patients undergo a pharyngeal swab at time of hospitalization. Our breast unit delays surgical treatment for low-grade tumors and ductal carcinoma in situ, while other breast cancer patients are offered lumpectomy or mastectomy as needed. Patients are evaluated case by case by a multidisciplinary team composed by breast surgeon, oncologist, radiologist and plastic surgeon to minimize the exposure to COVID-19 without compromising oncological safety and offering the best possible aesthetic outcome. The plastic surgeon purpose should be to achieve a satisfactory aesthetic result by adopting the easiest technique, limiting as much as possible operating times, risk of postoperative complication, duration of hospitalization, and outpatient v...

Breast Reconstruction during the COVID-19 Pandemic: A Systematic Review

“…In the place of ABR, several studies detailed exclusive use of implant-based reconstruction (in particular, direct-to-implant reconstruction), breast conservation surgery, or mastectomy alone. 6 , 13 , 14 , 17 , 18 , 21 – 23 , 26 , 27 Many authors cautioned the dangers of overlooking ABR and relying too heavily on implant-based breast reconstruction, and three studies described the successful resumption of ABR and established its safety during the COVID-19 pandemic. 4 , 15 , 24 , 25 One commentary described successful ABR in an asymptomatic carrier of COVID-19 in March 2020, the early stage of the pandemic before COVID-19 guidelines had been established.…”

“…Nearly all studies offered guidance on how to perform breast reconstruction during the pandemic; however, only 10 studies discussed the development of specific protocols. 14 , 16 , 18 , 20 , 24 , 26 , 27 , 30 , 34 , 35 …”

Impact of the COVID‐19 pandemic on a breast cancer surgery program. Observational case‐control study in a COVID‐free hospital

“…Secondly, COVID‐free hospitals facilitate the maintenance of cancer programs, as long as screening for the infection is guaranteed in the treated patients. Various European studies 1‐5 have provided their experience with patients with breast cancer during the COVID‐19 pandemic but have not reported the impact on hospital resources or on the delay in treating these patients. The aim of this study was to analyze the impact of the COVID‐19 pandemic on an oncologic surgery program in our hospital's breast unit.…”

“…Various European studies [1][2][3][4][5] Patients treated during the same dates in 2019 were the control group. A total of 93 patients were diagnosed during the study period; of these, 72 underwent surgery and 21 underwent primary systemic therapy ( Figure 1).…”

Management of non-invasive tumours, benign tumours and breast cancer during the COVID-19 pandemic: recommendations based on a Latin American survey

“…Regarding immediate breast reconstruction with implants or tissue expanders, it has been recommended that it could be performed depending on hospital resources, limiting as much as possible the times of the operation, the risk of postoperative complications, the duration of hospitalisation and outpatient visits [ 8 ]. Autologous (flap) reconstructions should be delayed.…”