gms | German Medical Science

GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW

Deutsche Gesellschaft für Plastische und Wiederherstellungschirurgie (DGPW)

ISSN 2193-8091

Breast reconstruction during the COVID-19 pandemic in resource-limited settings

Brustrekonstruktion während der COVID-19-Pandemie in ressourcenbeschränkten Umgebungen

Review Article

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  • corresponding author Sammy Al-Benna - Division of Plastic and Reconstructive Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
  • Andreas Gohritz - Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland

GMS Interdiscip Plast Reconstr Surg DGPW 2021;10:Doc10

doi: 10.3205/iprs000160, urn:nbn:de:0183-iprs0001603

Published: September 8, 2021

© 2021 Al-Benna et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at


The coronavirus disease 2019 (COVID-19) is a novel, rapidly changing pandemic. It has affected specialized medical services in unprecedented ways. Surgical decision making, always the most important aspect of care has taken on an added layer of complexity in the face of the COVID-19 pandemic. Therefore, recommendations for breast reconstruction during COVID-19 remain challenging and unclear. This article reviews the impact of the COVID-19 pandemic and suggests potential approaches that could be considered in the absence of validated strategies in breast reconstruction.

Keywords: reconstructive surgical procedures, mammaplasty, breast implantation, surgical flaps, severe acute respiratory syndrome coronavirus 2, COVID-19, pandemics


COVID-19 (Coronavirus Disease 2019) ist eine neuartige, sich schnell verändernde Pandemie. Sie hat spezialisierte medizinische Dienstleistungen in nie dagewesener Weise beeinflusst. Die chirurgische Entscheidungsfindung, immer der wichtigste Aspekt der Versorgung, hat angesichts der COVID-19-Pandemie eine zusätzliche Ebene der Komplexität angenommen. Daher bleiben die Empfehlungen für die Brustrekonstruktion während COVID-19 herausfordernd und unklar. Dieser Artikel gibt einen Überblick über die Auswirkungen der COVID-19-Pandemie und schlägt mögliche Ansätze vor, die in Ermangelung validierter Strategien bei der Brustrekonstruktion in Betracht gezogen werden könnten.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped, positive-sense, single-stranded RNA β-coronavirus [1]. SARS-CoV-2, which causes the disease known as coronavirus disease 2019 (COVID-19), was first reported in late 2019 in Wuhan, China and has rapidly developed into a global pandemic and public health emergency [1], [2], [3]. As of 1st September 2020, a total of 25,671,607 accumulated cases and 855,649 deaths have been reported worldwide, and South Africa is the current epicentre of the COVID-19 pandemic in sub-Saharan Africa [4], [5]. This pandemic places a strain on healthcare systems and providers, as well as forcing difficult choices about whether care can and should be delayed or reprioritized [5], [6]. The need to dedicate major economic, infrastructural, and medical resources to the assistance of critically ill COVID-19 patients is causing a redistribution of the activities of several medical disciplines not primarily involved in the management of COVID-19 patients [5], [6]. Given the varying natures of international healthcare systems, conditions differ significantly by locality; critical decisions concerning the deployment of resources and the management of elective surgical procedures should be made based on institutional policies and recommendations from local, state and federal authorities, considering the availability of finite and essential resources [2], [3], [5], [6]. Health care professionals have a responsibility to maximise the use of these resources to provide the best possible care for all patients. Patients must be informed of local and national service constraints and be given the opportunity to understand their planned treatment within allowable resources [2], [3], [5], [6], [7]. High level ACE2 gene expression has been demonstrated in skin, fat and breast tissue [8], [9], [10]. In addition, changes in wound healing pathophysiology and free flap failures have been associated with COVID-19 [11], [12]. This article focuses on the effects of the COVID-19 pandemic on breast reconstruction and suggests potential approaches that could be considered in the absence of validated strategies.

Breast reconstruction prior to COVID-19

Breast cancer is the most common malignancy in women worldwide, with over 2 million new cases diagnosed per year, contributing over 25% to new cancer cases diagnosed (excluding non-melanoma skin cancer) [13]. There has been an increase in the incidence with a rate of up to 3.5% over the preceding decade [13]. Surgery remains the foundation of treatment for breast cancer worldwide, and current current trends in surgical care including breast conservation surgery, mastectomy and reconstruction [14], [15], [16], [17], [18], [19]. There has been a paradigm shift in the management of breast cancer and the advent of oncoplastic breast surgery has revolutionised the concept of breast preservation, utilising limited tissue resection as opposed to a mastectomy [20], [21], [22], [23], [24], [25], [26], [27]. Although breast conservation therapy can be an attractive alternative, it is dependent upon a number of clinical factors including tumour size and location, and importantly approximately 40% of women with primary breast cancer still undergo mastectomy [14], [27], [28], [29], [30], [31], [32], [33].

A diagnosis of breast cancer and subsequent treatments are stressful events in a patient’s life, associated with an increased risk of anxiety, depression and psychosocial implications [34], [35], [36]. The decision to proceed with a mastectomy can lead to a feeling of loss of feminity, issues around sexuality and self-esteem as well as practical problems associated around clothing and the wearing of a prosthesis [34], [35]. Accordingly, a growing mumber of women now seek immediate reconstruction after mastectomy [25], [26]. This may be seen as an integral addition to their breast cancer treatment, resulting in improvements to their appearance and general well-being. The beneficial effects of breast reconstruction have been widely reported, and the vast majority of women is satisfied with the overall outcome, irrespective of the type of procedure undertaken [35], [36].

The timing of breast reconstruction following a mastectomy is important as there are a number of pertinent issues that need to be taken into consideration when opting for an immediate versus delayed reconstruction [34], [35]. These include the patient's body form, general health, breast cancer management as well as patient's preference [14].

At most breast centres, the majority of reconstructions is performed immediately, in a joint procedure between the breast surgeon, who performs the mastectomy, and the plastic surgeon [15], [19], [31], [34], [35], [36], [37]. Pre-operatively, this allows for mastectomy skin sparing incisions to be discussed between the two teams which can then be incorporated in the final decision on the optimal reconstruction to best suit the patient. Immediate breast reconstruction confers many advantages, mostly associated with an improved aesthetic appearance. It can also reduce numerous incisional scars and the need for multiple operations as well as offering significant psychological benefit with the restoration of the breast.

A major concern that can arise from an immediate reconstruction is a potential delay in patients receiving adjuvant therapy, i.e. radiotherapy and/or chemotherapy whilst recovering from surgery. Multi-disciplinary teams involving the oncologists as well as the surgeons work together to prevent this occurring. However, if there are certain patient co-morbidities that could prolong the post-operative recovery period, then a delayed reconstruction may be a more viable option. usually a year after completion of adjuvant therapy. Unfortunately, radiotherapy or scar tissue due to the mastectomy may affect wound healing as well as the integrity of vessels critical for the survival of autologous reconstruction and patients will be made aware of this.

Delayed reconstruction is also an option for many patients who are overwhelmed with their recent diagnosis and respective surgical treatment [34], [35], [36]. lt gives them time to make a fully informed decision before choosing the type of reconstruction that would benefit them [34], [35], [36].

A third option of immediate-delayed reconstruction may provide an alternative solution for those patients awaiting histological confirmation and possible post-mastectomy radiotherapy [36]. In this situation, a saline tissue expander implant is placed at the time of mastectomy protecting the breast skin envelope and remains until the patient completes the radiation cycle [30], [32], [36]. They can then undergo the standard delayed reconstruction. If radiotherapy is not required, the implant can be exchanged for a reconstructive procedure at an earlier date [32].

Autologous breast reconstruction

The aim of reconstruction is to recreate a breast “footprint” that is similar in shape, form and consistency to the natural/contralateral breast [16], [30], [35], [36]. Hence, breast reconstruction employs either autologous tissue or a non-autologous procedure to achieve a pleasing aesthetic result [7], [36].

Immediate breast reconstruction with autologous tissue is the preferred method, favoured by many patients and involves the microsurgical transfer of tissue from one area of the body to recreate the new breast. The type of flap is individualised to the patient’s needs as well as optimising the use of available tissue [14], [16]. At our institution, the most common flaps carried out are the deep inferior epigastric artery perforator (DIEAP) flap followed by the pedicled latissimus dorsi flap (LD) [14], [16], [38]. The gold standard for autologous reconstruction in the post-mastectomy patient remains the DIEAP flap, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options on the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap) and trunk (lumbar artery perforator flap, superior and inferior gluteal artery perforator flaps) [38], [39].

The DIEP flap, which is based on the deep inferior epigastric artery and vein, necessitates the presence of excess lower abdominal tissue. The procedure involves identification and meticulous dissection of the vessels as they course through the rectus abdominis muscle to the proximal pedicle of the external iliac artery and vein. The vessels are carefully isolated and transected together with excision of excess skin and subcutaneous tissue (referred to as a skin paddle) from the lower abdomen. The flap of tissue is then sculptured on the table to create a breast shape relative to the contralateral side before insetting into the new reconstructed breast. The flap is microsurgically anastomosed to the internal mammary or thoracodorsal vessels to re-establish blood perfusion.

Prior to the advent of the DIEAP free flap, the TRAM (transverse rectus abdominis myocutaneous) flap was the gold standard for breast reconstruction and involved a similar technique of harvesting the skin paddle but in addition to muscle from the lower abdomen. It can be associated with significant donor site morbidities including a reduced abdominal strength and development of an incisional hernia.

If the patient lacks adequate abdominal soft tissue, a transverse myocutaneous gracilis flap (TUG) can be reconstructed [40]. This recruits skin, subcutaneous tissue and muscle from the upper thigh which is based on the cutaneous gracilis perforators from the medial femoral circumflex system [40]. It is particularly advantageous as it provides minimal donor site morbidity and a scar that is acceptable to the patient [41].

The pedicled latissimus dorsi flap is a suitable alternative for those patients who are unwilling to accept abdominal weakness or who lack excess tissue [42]. It employs a small ellipse of skin and muscle from the back based on its own blood supply, and is advanced into the new breast via a dissected tunnel within the axilla. The use of part of the latissimus dorsi does not cause any adverse restrictions on shoulder function due to the synergistic effect of the rotator cuff muscles which can compensate for normal activities [43]. This flap was introduced at a time when radical mastectomy involved resection of the pectoralis major muscle with remnant thin skin flaps. The LD flap not only provides optimal soft tissue and muscle replacement to enhance the new breast shape but permits adequate coverage in the use of a breast implant [44].

Autologous reconstruction offers many benefits: It replaces like for like tissue, eliminates the need for implants in the majority of cases and creates a natural looking breast footprint [45]. Furthermore, the reconstructed tissue can alter in size, keeping with weight gain or loss and never requires replacement as seen with breast implants. Finally, many patients welcome the essential abdominoplasty that is required to harvest abdominal tissue for the DIEAP/TRAM flap.

Breast reconstruction is a complex procedure that is associated with complications which include bleeding, flap failure due to a compromised blood supply, fat necrosis of the new breast tissue and donor site morbidity, such as the development of a seroma or abscess collection. Unfortunately, this may necessitate the patient returning to the operating theatre to salvage the flap. It this is not possible, the dead tissue is removed and further options for reconstruction are discussed.

One of the major concerns highlighted is a potential risk for loco-regional recurrence due to skin sparing techniques [46]. However, research has proven a combination of skin sparing mastectomy and immediate reconstruction to have a low recurrence rate of 5.5% with invasive breast cancers and 0% for in-situ following a 6-year study [46].

Post-operatively the patient is transferred to a high dependency unit under the care of a specialised breast nurse who assesses the flap on an hourly basis for the first 24 hours as well as carrying out close monitoring of the patient’s vital observations, i.e. blood pressure, heart rate etc. The first 24–48 hours are crucial in early identification of any potential complications that could affect flap survival. Following this period, the patient is encouraged to sit up and gently mobilise with discharge planned 5–7 days post-operatively.

Non-autologous breast reconstruction

Non-autologous reconstruction incorporates the use of implants which may be permanent depending on the shape and volume of the breast mound desired by the patient [17], [18], [44], [47], [48]. They can be silicone or saline filled, but the former is believed to be superior in creating a soft and aesthetically pleasing breast shape. Another alternative is the use of tissue expanders, which are placed under the pectoralis major muscle and inflated at weekly intervals to allow for expansion of the overlying tissues [31], [36]. This can then be replaced with a permanent implant once the desired volume is achieved [31], [36]. Although the use of breast implants can be advantageous in breast reconstruction as it provides an aesthetically pleasing result with a short recovery period, it is not recommended for patients undergoing post-mastectomy radiotherapy due to the potential risk of wound breakdown and extrusion [31], [32], [33], [47].

Predominantly, breast implants are associated with a risk of capsular contraction due to the formation of a thickened fibrous capsule which surrounds the implant (encapsulation) and causes a distortion of the breast shape as well as immense discomfort to the patient [47]. However, this is surgically correctable by successfully releasing the capsule and replacing the implant [48]. The lifespan of implants in the framework of breast reconstruction is limited, with silicone gel implants lasting approximately 16.4 years, and saline implants for 108 months [48].

The final stage of reconstruction involves recreating the nipple and areolar complex, which is considered an integral part of the procedure [49]. Local bilobed or tri-lobed skin flaps are raised and fashioned into a new nipple, and this procedure can be performed 4–6 months after the major reconstruction [49]. This can be followed at a later stage with tattooing to recreate the areolar complex [49]. Patients are also offered a modification of the contralateral breast if they are unhappy with the degree of asymmetry [50], [51]. This involves a mastopexy, reduction or augmentation with a breast implant for completion [50], [51].

Breast cancer, breast reconstruction and COVID-19

Patients with cancer are at

an elevated risk for contracting COVID-19;
increased risk of a more severe infection; and
increased risk of developing complications and severe events related to COVID-19,

necessitating ICU admission with a higher mortality rate, due to their immunodepression, poor functional status, and frequent hospital visits and admissions [8], [9], [10], [52]. A study 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 [53].

Breast reconstruction is associated with significantly improved quality of life and mental health after mastectomy [34], [35]. Breast reconstruction itself can fundamentally be classified into three classes [14] including

implant- and expander-based breast reconstruction,
flap-based breast reconstruction (vascularized autologous tissue), a combination of both (flap and implant), and
breast reconstruction using fat grafting (non-vascularized autologous lipoaspirate fat).

Mastectomy with immediate implant-based breast reconstruction has risen to be the most common method due to advances in meshes and implants [26], [45], [54] and has the advantages of improved body image, improved health-related quality of life and higher patient satisfaction compared to those who opt for delayed reconstruction [34], [35]. Pre-pectoral implant-based reconstruction in the delayed-immediate autologous reconstruction leads to significantly lower complication rates and shorter intervals between staged surgeries [36]. A systematic review of infection rates and acellular dermal matrix breast reconstruction found a higher infection rate associated with acellular dermal matrix reconstruction (11.59%) compared with the non- acellular dermal matrix patients (4.74%) [55]. Breast conservation surgery compared to the alternative of mastectomy has gained momentum following the results of large clinical trials which demonstrated equivalent long-term survival, despite a higher local recurrence [56], [57], [58]. In patient with mastectomy post breast conserving surgery and radiation therapy, delayed autologous microvascular breast reconstruction is a safer decision [34], [35], [36].

The onset of the COVID-19 pandemic has changed the face of the treatment of post-ablative breast reconstruction globally [52]. Reconstruction should still be discussed wherever possible, but thought should be given to minimising extent of surgery, stay in hospital and risk of complications during the pandemic. In line with South African government directives, our institution limits elective surgery to oncologic procedures, and the reconstructive time is still considered an integrated part of the treatment. Patients are evaluated case by case by a multidisciplinary team composed by breast surgeon, oncologist, pathologist, radiologist and plastic surgeon to minimize the exposure to COVID-19 without compromising oncological safety and offering the best possible aesthetic outcome. The function of the reconstructive surgeon is to attain a satisfactory aesthetic result. Reconstruction is discussed when probable, but thought is given to minimising operating times, in-hospital stay (day case and 24 hours stay procedures), risk of complications and number of out-patient visits (e.g., tissue expander inflation) during the pandemic to control the risk of SARS-CoV-2 exposure to the patient and health care staff [59], [60]. Only the breast with cancer is addressed to avoid prolonged surgery by avoiding concurrent contralateral balancing procedures. Neither prophylactic breast surgery for risk reducing mastectomies (e.g. for high genetic risk) nor its reconstruction should be performed until post COVID-19 pandemic. In addition, secondary, revision (e.g. fat grafting) and delayed post-ablative reconstruction are elective and therefore are be postponed until the local health care system has capacity for “safe“ elective surgery. Fat grafting is predominantly used to refine post-reconstructive asymmetries and should not be performed during the COVID-19 pandemic. Day case and 24 hours stay procedures can be performed but procedures requiring longer hospital admission should be avoided (e.g. free flap autologous breast reconstruction). Delayed reconstructive breast surgery post COVID-19 pandemic hypothetically offers the safest approach [61].

It is important for the patient to be fully informed about the risks and benefits of the procedure taking into consideration the risk of hospital acquired COVID-19 infection. At present, decision making may be within present ethical/practice standards and follow accepted guidelines and protocols [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72]. However, should the burden on health services continue to escalate as has been seen in other countries decision making may be more extraordinary. Clear, open and transparent decision-making is also particularly important during the pandemic response [68], [69], [70], [71], [72]. In these conditions, it is critical that when the decision is made, both the decision process and decision made is well documented [68], [69], [70], [71], [72].

Recommended procedures for breast reconstruction during COVID-19 pandemic

Immediate breast reconstruction using prepectoral implants or tissue expanders can continue after case-by-case multidisciplinary discussions of the patient’s individual risk factors (e.g. age, co-morbidities, radiation) and a change in future reconstructive options (i.e anticipated radiation therapy), or when conservation of the the skin envelope of the breast will facilitate a potential delayed autologous microvascular breast reconstruction. In addition, consideration must be given to the current availability of local health care system resources. This immediate breast reconstruction, by the prepectoral or tissue expander implant, at the time of the primary breast tumour resection leads to only slightly extended surgical times, but still preserves the breast skin which allows for a potential second step delayed autologous microvascular breast reconstruction.

Simple oncoplastic procedures including mammoplasty and integration of perforator flaps for volume replacement can be performed [73]. In fact ‘oncoplastic’ techniques to avoid the need for mastectomy should be encouraged to enhance less invasive surgery [73]. Palliative and salvage mastectomy procedures that expose the thoracic wall should be reconstructed immediately with local pivot flaps [73], [74].

Mastectomy scar placement should be discussed with the reconstructive surgeon in preparation for delayed oncoplastic procedures. Healthy mastectomy flaps will facilitate delayed and excision of excess skin should be limited except where viability is of concern. Placement of drains should preserve perforators and vessels to allow reconstructive flap options for possible delayed partial breast reconstruction.


Breast reconstruction practice must be fluid and adapt to changing circumstances with close co-operation between breast and plastic surgeons working synergistically within a multidisciplinary team [70].

High level ACE2 gene expression has been demonstrated in skin, fat and breast tissue [8], [9], [10]. In addition, free flap failures have been associated with COVID-19 [11]. Post-ablative breast reconstruction is best kept straightforward and trouble-free during the COVID-19 pandemic. The pandemic is at different stages of the curve worldwide and resumption of post-ablative breast reconstruction practice should closely mirror local and national guidelines and exercise due caution to minimise risks of complications whilst addressing clinical need and patient expectations. Immediate breast reconstruction poses a unique surgical dilemma during COVID-19 as it straddles both urgent and elective forms of surgery. Expectations must be realistic with appropriate selection of patients and adherence to a fully informed consent process that reflects the additional risks associated with COVID-19. Individual risk assessment within an oncoplastic multidisciplinary team should help to risk stratify patients based on the latest data [75].

The existing data suggest that surgery may have a negative impact on the outcome of COVID-19 positive patients; however, there is currently insufficient evidence to deny patients the benefits of an immediate reconstruction. Reconstructive breast options will be restricted for the period of the COVID-19 pandemic, but there is opportunity to offer selected reconstructive options depending on local circumstances, operating capacity and the pandemic phase. We propose that breast reconstructive surgeons should consider only addressing the cancer side with immediate breast reconstruction using prepectoral “babysitter” implants or tissue expanders and greater use of therapeutic mammaplasty procedures that will only slightly extend surgical times. With the intention of counteracting some of the disadvantages of COVID-19 on breast cancer patients, breast conserving surgery should be considered when possible. Autologous microvascular breast reconstruction, complex oncoplastic procedures and all revisional breast reconstruction procedures should be recommenced safely once the peak of COVID-19 transmission has passed, as long as patients are suitably selected and appropriate modifications are considered. The recommendations considered in this article remain to be validated in future studies.

Competing interests

The authors declare that they have no competing interests.


Heymann DL, Shindo N; WHO Scientific and Technical Advisory Group for Infectious Hazards. COVID-19: what is next for public health? Lancet. 2020;395:542-5. DOI: 10.1016/S0140-6736(20)30374-3 External link
Al-Benna S. Availability of COVID-19 Information from National and International Aesthetic Surgery Society Websites. Aesthetic Plast Surg. 2020 06;44(3):1043-6. DOI: 10.1007/s00266-020-01751-w External link
Al-Benna S, Gohritz A. Availability of COVID-19 Information From National Plastic Surgery Society Web Sites. Ann Plast Surg. 2020 Aug;85(2S Suppl 2):S171-S172. DOI: 10.1097/SAP.0000000000002447 External link
Worldometer. COVID-19 Coronavirus Pandemic. [last accessed 2020 Sep 1]. Available from: External link
Al-Benna. Impact of COVID-19 on Surgical Registrars' Education and Training. S Afr J Surg. 2020;58:10-3.
Thomson S, Krige J. COVID-19 in perspective. S Afr J Surg. 2020;58(3):122-9. DOI: 10.17159/2078-5151/2020/v58n3a3348 External link
Soran A, Gimbel M, Diego E. Breast Cancer Diagnosis, Treatment and Follow-Up During COVID-19 Pandemic. Eur J Breast Health. 2020 Apr;16(2):86-8. DOI: 10.5152/ejbh.2020.240320 External link
Al-Benna S. Gene Expression of Angiotensin-Converting Enzyme 2 Receptor in Skin and the Implications for COVID-19. Adv Skin Wound Care. 2021 Jan;34(1):31-5. DOI: 10.1097/01.ASW.0000722748.73437.7d External link
Al-Benna S. Association of high level gene expression of ACE2 in adipose tissue with mortality of COVID-19 infection in obese patients. Obes Med. 2020 Sep;19:100283. DOI: 10.1016/j.obmed.2020.100283 External link
Al-Benna S. Gene Expression in Breast Tissue. Eur J Breast Health. 2021 Apr;17(2):112-5. DOI: 10.4274/ejbh.galenos.2021.6007 External link
Al-Benna S. Failure of Free Flaps in Head and Neck Oncology Surgery in COVID-19 Patients. Plast Reconstr Surg. 2021 Mai;147(5):900e-1e. DOI: 10.1097/PRS.0000000000007847 External link
Al-Benna S. Pathophysiology of coronavirus disease 2019 for wound care professionals. Int Wound J. 2020 Dec;17(6):1935-40. DOI: 10.1111/iwj.13483 External link
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. DOI: 10.3322/caac.21492 External link
Al-Benna S. Female plastic and reconstructive surgeons' personal decision making for breast cancer treatment and reconstruction. Arch Gynecol Obstet. 2011 Sep;284(3):737-41. DOI: 10.1007/s00404-010-1721-9 External link
Ter Stege JA, Oldenburg HSA, Woerdeman LAE, Witkamp AJ, Kieffer JM, van Huizum MA, van Duijnhoven FH, Hahn DEE, Gerritsma MA, Kuenen MA, Kimmings NAN, Ruhé QPQ, Krabbe-Timmerman IS, Riet MV, Corten EML, Sherman KA, Bleiker EMA. Decisional conflict in breast cancer patients considering immediate breast reconstruction. Breast. 2021 Feb;55:91-7. DOI: 10.1016/j.breast.2020.12.001 External link
Chang EI. Latest Advancements in Autologous Breast Reconstruction. Plast Reconstr Surg. 2021 Jan;147(1):111e-2e. DOI: 10.1097/PRS.0000000000007480 External link
Colwell AS, Taylor EM. Recent Advances in Implant-Based Breast Reconstruction. Plast Reconstr Surg. 2020 Feb;145(2):421e-32e. DOI: 10.1097/PRS.0000000000006510 External link
Frey JD, Salibian AA, Karp NS, Choi M. Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions. Plast Reconstr Surg. 2019 Feb;143(2):404e-16e. DOI: 10.1097/PRS.0000000000005290 External link
Kaidar-Person O, Poortmans P, Offersen BV, Boersma LJ, de Ruysscher D, Noy V, Hermann N, Kühn T. What are the guidelines for immediate breast reconstruction? Eur J Surg Oncol. 2021 May;47(5):1214-5. DOI: 10.1016/j.ejso.2020.03.226 External link
Jin S, Xu B, Shan M, Liu Y, Han J, Zhang G. Clinical Significance of Oncoplastic Breast-Conserving Surgery and Application of Volume-Displacement Technique. Ann Plast Surg. 2021 Feb;86(2):233-6. DOI: 10.1097/SAP.0000000000002477 External link
Losken A, Chatterjee A. Improving Results in Oncoplastic Surgery. Plast Reconstr Surg. 2021 Jan;147(1):123e-34e. DOI: 10.1097/PRS.0000000000007478 External link
Chu CK, Hanson SE, Hwang RF, Wu LC. Oncoplastic partial breast reconstruction: concepts and techniques. Gland Surg. 2021 Jan;10(1):398-410. DOI: 10.21037/gs-20-380 External link
Crown A, Handy N, Weed C, Laskin R, Rocha FG, Grumley J. Oncoplastic Breast-Conserving Surgery: Can We Reduce Rates of Mastectomy and Chemotherapy Use in Patients with Traditional Indications for Mastectomy? Ann Surg Oncol. 2021 Apr;28(4):2199-209. DOI: 10.1245/s10434-020-09044-x External link
Gilmour A, Cutress R, Gandhi A, Harcourt D, Little K, Mansell J, Murphy J, Pennery E, Tillett R, Vidya R, Martin L. Oncoplastic breast surgery: A guide to good practice. Eur J Surg Oncol. 2021. DOI: 10.1016/j.ejso.2021.05.006 External link
Albornoz CR, Bach PB, Mehrara BJ, Disa JJ, Pusic AL, McCarthy CM, Cordeiro PG, Matros E. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013 Jan;131(1):15-23. DOI: 10.1097/PRS.0b013e3182729cde External link
Jagsi R, Jiang J, Momoh AO, Alderman A, Giordano SH, Buchholz TA, Kronowitz SJ, Smith BD. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol. 2014 Mar;32(9):919-26. DOI: 10.1200/JCO.2013.52.2284 External link
Margenthaler JA, Dietz JR, Chatterjee A. The Landmark Series: Breast Conservation Trials (including oncoplastic breast surgery). Ann Surg Oncol. 2021 Apr;28(4):2120-7. DOI: 10.1245/s10434-020-09534-y External link
Rocco N, Catanuto G, Cinquini M, Audretsch W, Benson J, Criscitiello C, Di Micco R, Kovacs T, Kuerer H, Lozza L, Montagna G, Moschetti I, Nafissi N, O'Connell RL, Oliveri S, Pau L, Scaperrotta G, Thoma A, Winters Z, Nava MB. Should oncoplastic breast conserving surgery be used for the treatment of early stage breast cancer? Using the GRADE approach for development of clinical recommendations. Breast. 2021 Jun;57:25-35. DOI: 10.1016/j.breast.2021.02.013 External link
Huang S, Qiu P, Li J, Liang Z, Yan Z, Luo K, Huang B, Yu L, Chen W, Zhang Y. Strategies for the selection of oncoplastic techniques in the treatment of early-stage breast cancer patients. Gland Surg. 2021 May;10(5):1687-700. DOI: 10.21037/gs-21-212 External link
Heiman AJ, Gabbireddy SR, Kotamarti VS, Ricci JA. A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy. J Reconstr Microsurg. 2021 May;37(4):336-45. DOI: 10.1055/s-0040-1716846 External link
Jung SM, Jeon BJ, Woo J, Ryu JM, Lee SK, Chae BJ, Yu J, Kim SW, Nam SJ, Pyon JK, Mun GH, Bang SI, Lee JE. Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander? BMC Cancer. 2021 Jan;21(1):88. DOI: 10.1186/s12885-020-07729-w External link
Chung SY, Chang JS, Shin KH, Kim JH, Park W, Kim H, Kim K, Lee IJ, Yoon WS, Cha J, Lee KC, Kim JH, Choi JH, Ahn SJ, Ha B, Lee SY, Lee DS, Lee J, Shin SO, Lee SW, Choi J, Kim MY, Kim YJ, Im JH, Suh CO, Kim YB. Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: A multi-institutional validation study. Breast. 2021 Apr;56:7-13. DOI: 10.1016/j.breast.2021.01.003 External link
Kim H, Kang D, Park W, Cho J, Park H, Kim E, Choi DH, Cho WK, Jeon BJ, Lee KT. Impact of Breast Reconstruction on Biophysical Parameters of Mammary Skin in Patients Receiving Postmastectomy Radiotherapy for Breast Cancer. J Breast Cancer. 2021 Apr;24(2):206-17. DOI: 10.4048/jbc.2021.24.e23 External link
Siqueira HFF, Teixeira JLA, Lessa Filho RDS, Hora EC, Brasileiro FF, Borges KS, Brito ÉAC, Lima MS, Marques AD, Moura AR, Figueiredo Júnior TC, de Oliveira TC, Vasconcelos AAS, Lima CA. Patient satisfaction and quality of life in breast reconstruction: assessment of outcomes of immediate, delayed, and nonreconstruction. BMC Res Notes. 2020 Apr;13(1):223. DOI: 10.1186/s13104-020-05058-6 External link
Beugels J, Kool M, Hoekstra LT, Heuts EM, Tuinder SMH, van der Hulst RRWJ, Piatkowski A. Quality of Life of Patients After Immediate or Delayed Autologous Breast Reconstruction: A Multicenter Study. Ann Plast Surg. 2018 Nov;81(5):523-7. DOI: 10.1097/SAP.0000000000001618 External link
Patel AA, Borrelli MR, Cai L, Moshrefi S, Sando IC, Lee GK, Nazerali RS. Comparing Prepectoral Versus Subpectoral Tissue Expander Placement Outcomes in Delayed-Immediate Autologous Breast Reconstruction. Ann Plast Surg. 2020 05;84(5S Suppl 4):S329-S35. DOI: 10.1097/SAP.0000000000002402 External link
Omranipour R, Bobin JY, Esouyeh M. Skin Sparing Mastectomy and Immediate Breast Reconstruction (SSMIR) for early breast cancer: eight years single institution experience. World J Surg Oncol. 2008 Apr;6:43. DOI: 10.1186/1477-7819-6-43 External link
Seth AK, Allen RJ Jr. Modern techniques and alternative flaps in microsurgical breast reconstruction. J Surg Oncol. 2018 Oct;118(5):768-79. DOI: 10.1002/jso.25198 External link
Myers PL, Nelson JA, Allen RJ Jr. Alternative flaps in autologous breast reconstruction. Gland Surg. 2021 Jan;10(1):444-59. DOI: 10.21037/gs.2020.03.16 External link
Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg. 2008 Nov;122(5):1326-33. DOI: 10.1097/PRS.0b013e318188205f External link
Pülzl P, Schoeller T, Kleewein K, Wechselberger G. Donor-site morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: short-term and long-term results. Plast Reconstr Surg. 2011 Oct;128(4):233e-42e. DOI: 10.1097/PRS.0b013e3182268a99 External link
DeLong MR, Tandon VJ, Rudkin GH, Da Lio AL. Latissimus Dorsi Flap Breast Reconstruction-A Nationwide Inpatient Sample Review. Ann Plast Surg. 2017 May;78(5 Suppl 4):S185-S8. DOI: 10.1097/SAP.0000000000001079 External link
Sood R, Easow JM, Konopka G, Panthaki ZJ. Latissimus Dorsi Flap in Breast Reconstruction: Recent Innovations in the Workhorse Flap. Cancer Control. 2018 Jan-Mar;25(1):1073274817744638. DOI: 10.1177/1073274817744638 External link
Palve J, Luukkaala T, Kääriäinen M. Comparison of Different Techniques in Latissimus Dorsi Breast Reconstruction: Plain, Immediately Lipofilled, and Implant Enhanced. Ann Plast Surg. 2021 Mar. DOI: 10.1097/SAP.0000000000002798 External link
Masoomi H, Hanson SE, Clemens MW, Mericli AF. Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database. Ann Plast Surg. 2021 Jan. DOI: 10.1097/SAP.0000000000002664 External link
Fodor J, Major T, Tóth J, Sulyok Z, Polgár C. Comparison of mastectomy with breast-conserving surgery in invasive lobular carcinoma: 15-Year results. Rep Pract Oncol Radiother. 2011;16(6):227-31. DOI: 10.1016/j.rpor.2011.06.005 External link
Goodman CM, Cohen V, Thornby J, Netscher D. The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: a meta-analysis. Ann Plast Surg. 1998 Dec;41(6):577-85; discussion 585-6. DOI: 10.1097/00000637-199812000-00001 External link
Benadiba L, Pétoin DS, Berlie J, Rouëssé J, Girard M. Durée de vie des implants mammaires en reconstruction mammaire. A propos de 949 implants. Ann Chir Plast Esthet. 2000;45:31-40.
Paolini G, Firmani G, Briganti F, Sorotos M, Santanelli di Pompeo F. Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm. Aesthetic Plast Surg. 2021 Jun;45(3):933-45. DOI: 10.1007/s00266-020-02047-9 External link
Razdan SN, Panchal H, Albornoz CR, Pusic AL, McCarthy CC, Cordeiro PG, Disa JJ, Mehrara BJ, Matros E. Impact of Contralateral Symmetry Procedures on Long-Term Patient-Reported Outcomes following Unilateral Prosthetic Breast Reconstruction. J Reconstr Microsurg. 2019 Feb;35(2):124-8. DOI: 10.1055/s-0038-1667365 External link
Giordano S, Harkkila S, Oranges CM, di Summa PG, Koskivuo I. Immediate versus Delayed Contralateral Breast Symmetrisation in Breast Reconstruction with Latissimus dorsi Flap: A Comparative Study. Breast Care (Basel). 2019 Oct;14(5):272-6. DOI: 10.1159/000502769 External link
Çakmak GK, Özmen V. Sars-CoV-2 (COVID-19) Outbreak and Breast Cancer Surgery in Turkey. Eur J Breast Health. 2020 Apr;16(2):83-5. DOI: 10.5152/ejbh.2020.300320 External link
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Li C, Ai Q, Lu W, Liang H, Li S, He J. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335‐7. DOI: 10.1016/S1470-2045(20)30096-6 External link
Panchal H, Matros E. Current Trends in Postmastectomy Breast Reconstruction. Plast Reconstr Surg. 2017 Nov;140(5S Advances in Breast Reconstruction):7S-13S. DOI: 10.1097/PRS.0000000000003941 External link
Phillips BT, Bishawi M, Dagum AB, Bui DT, Khan SU. A Systematic Review of Infection Rates and Associated Antibiotic Duration in Acellular Dermal Matrix Breast Reconstruction. Eplasty. 2014;14:e42.
Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002 Oct;347(16):1227-32. DOI: 10.1056/NEJMoa020989 External link
Onitilo AA, Engel JM, Stankowski RV, Doi SA. Survival Comparisons for Breast Conserving Surgery and Mastectomy Revisited: Community Experience and the Role of Radiation Therapy. Clin Med Res. 2015 Jun;13(2):65-73. DOI: 10.3121/cmr.2014.1245 External link
Blichert-Toft M, Nielsen M, Düring M, Møller S, Rank F, Overgaard M, Mouridsen HT. Long-term results of breast conserving surgery vs. mastectomy for early stage invasive breast cancer: 20-year follow-up of the Danish randomized DBCG-82TM protocol. Acta Oncol. 2008;47(4):672-81. DOI: 10.1080/02841860801971439 External link
Al-Benna S. Management of hand surgery services during the Coronavirus Disease 2019 pandemic. J Hand Microsurg. 2020. DOI: 10.1055/s-0040-1714440. External link
Al-Benna S. Protective measures for burn care professionals during the coronavirus disease 2019 pandemic: Systematic Review. Ann Burns Fire Disasters. 2020;33:182-90.
Andree C, Langer S, Seidenstuecker K, Richrath P, Behrendt P, Koeppe T, Hagouan M, Witzel C, Al Benna S, Munder B. A single center prospective study of bilateral breast reconstruction with free abdominal flaps: a critical analyses of 144 patients. Med Sci Monit. 2013 Jun;19:467-74. DOI: 10.12659/MSM.883954 External link
Al-Benna S, Steinsträßer L. Postablative reconstruction is better terminology than oncoplastic surgery. Plast Reconstr Surg. 2009 Dec;124(6):463e-464e. DOI: 10.1097/PRS.0b013e3181bf7fe3 External link
Al-Benna S, Rajgarhia P. Blood transfusion requirements in elective breast reconstruction surgery. Breast. 2010 Dec;19(6):475-8. DOI: 10.1016/j.breast.2010.05.006 External link
Al-Benna S. The impact of late-starts and overruns on theatre utilisation rates. J Perioper Pract. 2021 Jun;22(6):197-9. DOI: 10.1177/175045891202200603. External link
Al-Benna S. Infection control in operating theatres. J Perioper Pract. 2012 Oct;22(10):318-22. DOI: 10.1177/175045891602201002 External link
Al-Benna S, Gohritz A. Availability of COVID-19 information from national and international burn society websites. Ann Burns Fire Disasters. 2020;33:177-81.
Al-Benna S, Gohritz A. Availability of COVID-19 information from national and international hand surgery society websites. J Hand Microsurg. 2020. DOI: 10.1055/s-0040-1718864. External link
Al-Benna S. Negative pressure rooms and COVID-19. J Perioper Pract. 2021 Jan-Feb;31(1-2):18-23. DOI: 10.1177/1750458920949453 External link
Al-Benna S, Steinstraesser L, Patani N. Free flap breast reconstruction consent forms should warn against the potential loss of the internal thoracic artery for coronary artery bypass grafting. Plast Reconstr Surg. 2012 May;129(5):867e-8e. DOI: 10.1097/PRS.0b013e31824a9e95 External link
Al-Benna S. Caution in the use of the internal mammary artery in breast reconstruction. Plast Reconstr Surg. 2007 Jul;120(1):348. DOI: 10.1097/01.prs.0000264563.48652.a6 External link
Al-Benna S, Al-Busaidi SS, Papadimitriou G, Schonauer F, Steinstrasser L. Abdominoplasty consent forms do not caution against the potential loss of a reconstructive option for breast reconstruction. Plast Reconstr Surg. 2009 Jun;123(6):208e-9e. DOI: 10.1097/PRS.0b013e3181a8490a External link
Al-Benna S, Grob M, Mosahebi A, Dheansa BS, Pereira J. Caution note on the use of the internal mammary artery in breast reconstruction. Plast Reconstr Surg. 2006 Apr;117(5):1653-4. DOI: 10.1097/01.prs.0000208865.31910.48 External link
Al-Benna S. Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction. Plast Reconstr Surg. 2021 May;147(5):878e-9e. DOI: 10.1097/PRS.0000000000007809 External link
Al-Benna S, Poggemann K, Steinau HU, Steinstraesser L. Diagnosis and management of primary breast sarcoma. Breast Cancer Res Treat. 2010 Aug;122(3):619-26. DOI: 10.1007/s10549-010-0915-y External link
Al-Benna S. Sword of Damocles: application of the ethical principles of resource allocation to essential cancer surgery patients requiring beds in limited supply during the COVID-19 pandemic. Eur Surg. 2020 Aug;:1-2. DOI: 10.1007/s10353-020-00655-y External link
Al-Benna S. Inflammatory and Coagulative Pathophysiology for the Management of Burn Patients With COVID-19. Ann Burns Fire Disasters. 2021;34:3-9.
Al-Benna S. Concepts of management of plastic surgery services during the coronavirus disease 2019 pandemic. Eur J Plast Surg. 2020 Jul;:1-2. DOI: 10.1007/s00238-020-01704-1 External link
Al-Benna S. Rural Plastic Surgery. Ann Plast Surg. 2021 Aug;87(2):230. DOI: 10.1097/SAP.0000000000002550 External link