Breast cancer is the most common cancer among women worldwide. Postmastectomy radiotherapy (PMRT) is an essential component of combined therapy for early-stage, high-risk breast cancer. Breast reconstruction (BR) is often considered for patients with breast cancer who have undergone mastectomy. There has been a considerable amount of discussion about the optimal approach to combining PMRT with BR in the treatment of breast cancer. PMRT may increase the risk of complications and prevent good aesthetic results after BR, while BR may increase the complexity of PMRT and the radiation dose to surrounding normal tissues. The purpose of this review is to give a broad overview and summary of the current controversies and trends in PMRT and BR in the context of the most recent literature available.

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BACKGROUND: Nipple-areola complex (NAC) necrosis is a major complication for breast reconstruction after nipple-sparing mastectomy. Although intraoperative indocyanine green angiography helps to assess the viability of tissue, the imaging could be conservative which may lead to aggressive resection. The plastic surgeons are eager to know the perfusion changes of NAC throughout the perioperative period.
METHODS: In this prospective cohort study, the authors enrolled patients who underwent NSM and immediate direct-to-implant breast reconstruction. All patients underwent laser speckle contrast imaging before surgery, immediately after mastectomy, after implant placement, and 24 h and 72 h after surgery.
RESULTS: A total of 94 breasts were analyzed, including 64 breasts healed with viable NAC and 30 breasts with NAC necrosis. In viable NACs, the average blood supply decreased to 56% after NSM and 42% after reconstruction, then recovered to 68% and 80% at 24-h and 72-h post-operation. In necrotic NACs, the average blood supply decreased to 33% after NSM and 24% after reconstruction, and partial perfusion recovery was also recorded at 24-h (31%) and 72-h (37%) post-operation. The cutoff value for predicting NAC viability is 40% after NSM and 25% after implant placement.
CONCLUSIONS: The study quantified the NAC perfusion changes during the perioperative period. NAC perfusion decreased significantly after NSM and would be the lowest after the end of breast reconstruction. Viable NACs displayed more perfusion during the operation and showed significant nipple revascularization after breast reconstruction.
METHODS: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: The volume of the implant is the most critical element of breast reconstruction, so it is necessary to accurately assess the preoperative volume of the healthy and affected breasts and select the appropriate implant for placement. Accurate and automated methods for quantitative assessment of breast volume can optimize breast reconstruction surgery and assist physicians in clinical decision making. The aim of this study was to develop an artificial intelligence model for automated segmentation of the breast and measurement of volume.
METHODS: A total of 249 subjects undergoing breast reconstruction surgery were enrolled in this study. Subjects underwent preoperative breast MRI, and the breast region manually outlined by the imaging physician served as the gold standard for volume measurement by the automated segmentation model. In this study, we developed three automated algorithms for automatic segmentation of breast regions, including a simple alignment model, an alignment dynamic encoding model, and a deep learning model. The volumetric agreement between the three automated segmentation algorithms and the breast regions manually segmented by imaging physicians was evaluated by calculating the mean square error (MSE) and intragroup correlation coefficient (ICC), and the reproducibility of the automated segmentation of the breast regions was assessed by the test-retest step.
RESULTS: The three breast automated segmentation models developed in this study (simple registration model, dynamic programming model, and deep learning model) showed strong ICC with manual segmentation of the breast region, with MSEs of 1.124, 0.693, and 0.781, and ICCs of 0.975 (95% CI, 0.869-0.991), 0.986 (95% CI, 0.967-0.996), and 0.983 (95% CI, 0.961-0.992), respectively. Regarding the test-retest results of breast volume, the dynamic programming model performed the best with an MSE of 0.370 and an ICC of 0.993 (95% CI, 0.982-0.997), followed by the deep learning algorithm with an MSE of 0.741 and an ICC of 0.983 (95% CI, 0.956-0.993), and the simple registration algorithm with an MSE of 0.763 and an ICC of 0.982 (95% CI, 0.949-0.993). The reproducibility of the breast region segmented by the three automated algorithms was higher than that of manual segmentation by different radiologists.
CONCLUSIONS: The three automated breast segmentation algorithms developed in this study generate accurate and reliable breast regions, enable highly reproducible breast region segmentation and automated volume measurements, and provide a valuable tool for surgical selection of appropriate prostheses.
METHODS: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

UNASSIGNED: To explore the effects of Beck\'s cognitive therapy on the anxiety of patients after breast reconstruction.
UNASSIGNED: This study retrospectively analyzed clinical data of 150 patients with breast cancer undergoing breast reconstruction from June 2020 to June 2021 in our hospital, excluded 5 patients who did not meet the inclusion criteria, divided the remaining cases into an experimental group (EG, n = 70, perioperative routine management + Beck\'s cognitive therapy intervention) and a reference group (RG, n = 75, perioperative routine management) in accordance with different perioperative intervention programs, and compared the emotions of anxiety and depression, sense of social disability, and prognosis quality in both groups.
UNASSIGNED: At 2 months after surgery (T2) and 3 months after surgery (T3), EG had overtly lower Hamilton Anxiety Scale (HAMA) and Beck Depression Inventory (BDI) scores than RG (P < .05), with no difference in HAMA and BDI scores at 3 days before surgery (T0) and 1 month after surgery (T1) (P > .05). At the T0 stage, both groups were diagnosed as having a social disability, with no overt difference (P > .05). At T1 stage, The Social Disability Screening Schedule (SDSS) scores in both groups increased remarkably and fell back at the T2 and T3 stages. At T1-T2 stages, SDSS scores of EG were significantly different from those of RG (P < .05), with no significant difference at T3 stage (P > .05). The excellent rate of prognosis in EG was 78.57% (55/70), higher than 77.33% (58/75) in RG, with no statistical difference in both groups (P < .05).
UNASSIGNED: The implementation of Beck\'s cognitive therapy in patients with breast reconstruction effectively improves adverse emotions in patients, which is of great significance for promoting postoperative rehabilitation and is an effective intervention program in the perioperative period.

In the vast expanse of restorative surgical procedures, the Deep Inferior Epigastric Perforator (DIEP) flap, originating from the inferior epigastric artery, has emerged as the preferred method of breast reconstruction, attributable to its myriad advantages. The technique provides reliable vascular supply, robust tissue volume for excision, minimal invasiveness to the donor site, with direct closure and concealment of the said site. This paper embarks on an elaborate elucidation of the DIEP surgical procedure, pivoting on the analytical exploration of a particular instance where necrosis of the skin flap occurred following immediate DIEP breast reconstruction in a patient diagnosed with early-stage breast cancer. This patient had previously undergone Nipple Areola Complex Sparing Mastectomy (NSM). We endeavor to extrapolate insights from this singular case of post-NSM DIEP breast reconstruction failure and correlate our findings with current literature dedicated to similar instances of surgical failure in DIEP breast reconstruction.

BACKGROUND: The laparoscopically harvested omental flap (LHOF) has been used in partial or total breast reconstruction, but most studies on LHOF were case reports or small case series. However, the clinical feasibility and oncological safety of LHOF in oncoplastic breast surgery remains controversial. This study reported our experience applying LHOF for immediate breast reconstruction.
METHODS: Between June 2018 and March 2022, 300 patients underwent oncoplastic breast surgery using LHOF at our institution. Their clinicopathological data, complications, cosmetic outcomes, and oncologic outcomes were evaluated.
RESULTS: All patients underwent total breast reconstruction using LHOF after nipple-sparing mastectomy. The median operation time was 230 min (ranging from 155 to 375 min). The median operation time for harvesting the omental flap was 55 min (ranging from 40 to 105 min). The success rate of the laparoscopically harvested pedicled omental flap was over 99.0%. Median blood loss was 70 ml, ranging from 40 to 150 ml. The volume of the flap was insufficient in 102 patients (34.0%). The overall complication rate was 12.3%. Subcutaneous fluid in the breast area (7%) was the most common reconstruction-associated complication, but most cases were relieved spontaneously. The incidence rate of omental flap necrosis was 3.3%. LHOF-associated complications occurred in two cases, including one case of incisional hernia and one case of vascular injury. Cosmetic outcomes were satisfactory in 95.1% of patients on a four-point scale by three-panel assessment and 97.2% using the BCCT.core software. Two local and one systemic recurrence were observed during a median follow-up period of 32 months.
CONCLUSIONS: The LHOF for immediate breast reconstruction is a safe and feasible method that involves minimal donor-site morbidity, satisfactory cosmetic outcomes, and promising oncologic safety.

OBJECTIVE: We propose a pedicled perforator flap technique for salvage nipple reconstruction after initial nipple reconstruction fails in breast cancer patients.
METHODS: This is a pilot study. A total of 21 female breast cancer patients who underwent nipple reconstruction following initial nipple reconstruction fails were enrolled, and salvage nipple reconstruction based pedicled perforator flap were performed between 2016 and 2020. Operative time, perforator design, postoperative complications, follow-up duration, projection of nipple, as well as patient-reported outcomes measured by the BREAST-Q and visual analogue scale (VAS) were assessed.
RESULTS: Sixteen patients underwent fifth lateral intercostal artery perforator reconstruction, while 5 patients underwent fifth anterior intercostal artery perforator flap reconstruction. The surgeries were successful without intraoperative complications, with a mean operative time of 67 minutes. Postoperative complications were absent. The mean follow-up duration was 18 months. The mean nipple projection was 8 mm (range, 6-10 mm) with a shrinkage of 20% at 6 months after surgery. The average scores for psychosocial well-being, satisfaction with breasts, and satisfaction with nipples domains of the BREAST-Q significantly increased (P < .01) at 6 months post-reconstruction. Sexual well-being subdomain showed no statistical difference (P = .9369). The VAS scores for cosmesis and patient satisfaction with surgery were 9 and 9.3, respectively.
CONCLUSIONS: The pedicled perforator flap technique for salvage nipple reconstruction is a safe and effective approach.

OBJECTIVE: Mastectomy, a common intervention for breast cancer, has substantial implications for a woman\'s quality of life (QoL). However, the literature on QoL outcomes following mastectomy-with or without breast reconstruction (BR) is scant. This study aims to assess and compare the QoL among Iraqi women post-mastectomy, examining the impacts of undergoing BR.
METHODS: We conducted a comprehensive cross-sectional study across multiple centers in Iraq from April to September 2021. Our cohort consisted of 404 women who had a mastectomy for breast cancer treatment, 154 of whom also chose to have BR. Utilizing the European Organisation for Research and Treatment of Cancer\'s (EORTC) tools specifically, select domains from EORTC QLQ-BR23, QLQ-C30, and QLQ-BRECON23-we evaluated various facets of their QoL.
RESULTS: The mean QoL score was 54 out of 100, with patients who did not undergo BR reporting slightly higher scores (55) compared to those who did (52). Notably, social and sexual functioning scores were statistically superior in the non-BR group. Satisfaction with surgery, sexual function, and breast aesthetics were the lowest rated aspects among BR patients, indicating a considerable gap between expectations and outcomes. Marital status and the type of mastectomy notably influenced body image and sexual function. A significant portion of patients (100 out of 250) opted out of BR due to recurrence concerns, while 26.2% (106 out of 154) pursued BR to restore their pre-mastectomy physique.
CONCLUSIONS: Contrary to the anticipated benefits of BR, our findings suggest that women who underwent the procedure reported a lower QoL compared to those who did not. The outcomes highlight the discrepancy between expected and actual benefits of BR, suggesting a pressing need for comprehensive rehabilitation programs. These programs should aim to enhance the QoL for post-mastectomy patients and provide in-depth counseling to align expectations with the potential realities of BR.

Preoperative selection of perforator is one of the key steps for successful surgery. The purpose of this study is to simulate the selection process of the perforator of the flap using the 3D models of the deep inferior epigastric artery (DIEA). A retrospective study was performed of women who underwent deep inferior epigastric perforator flap breast reconstruction from January 2011 to July 2021. Construct 3D models of the DIEA using computerized tomography angiography images, and then computational fluid dynamics simulations were performed. Correlation and regression analyses were used to analyze the geometric and hemodynamic parameters. Statistical analysis suggested that the outlet flow was positively correlated with the inlet area (r = 0.338, p = 0.000), outlet area (r = 0.840, p = 0.000), the average radius of the perforator (r = 0.592, p = 0.000), and negatively correlated with the length of perforator(r = -0.210, p = 0.024). The results of linear regression analysis showed that the outlet area (p = 0.000), the average radius (p = 0.000), and the length (p = 0.044) of the perforator were the influencing factors on outlet flow. In multiple perforators analysis, there was a significant difference in the total outlet flow among single perforator, double perforators, and triple perforators (p = 0.002). The successful implementation of this experiment provides a new approach for the selection of dominant perforators in the future.