Experiences of implant loss after immediate implant-based breast reconstruction: qualitative study

Gothenburg Breast reconstruction (GoBreast) II protocol: a Swedish partially randomised patient preference, superiority trial comparing autologous and implant-based breast reconstruction

INTRODUCTION

Although breast reconstruction is an integral part of breast cancer treatment, there is little high-quality evidence to indicate which method is the most effective. Randomised controlled trials (RCTs) are generally thought to provide the most solid scientific evidence, but there are significant barriers to conducting RCTs in breast reconstruction, making both recruitment and achieving unbiased and generalisable results a challenge. The objective of this study is to compare implant-based and autologous breast reconstruction in non-irradiated patients. Moreover, the study aims to improve the evidence for trial decision-making in breast reconstruction.

METHODS AND ANALYSIS

The study design partially randomised patient preference trial might be a way to overcome the aforementioned challenges. In the present study, patients who consent to randomisation will be randomised to implant-based and autologous breast reconstruction, whereas patients with strong preferences will be able to choose the method. The study is designed as a superiority trial based on the patient-reported questionnaire BREAST-Q and 124 participants will be randomised. In the preference cohort, patients will be included until 62 participants have selected the least popular alternative. Follow-up will be 60 months. Embedded qualitative studies and within-trial economic evaluation will be performed. The primary outcome is patient-reported breast-specific quality of life/satisfaction, and the secondary outcomes are complications, factors affecting satisfaction and cost-effectiveness.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority (2023-04754-01). Results will be published in peer-reviewed scientific journals and presented at peer-reviewed scientific meetings.

TRIAL REGISTRATION NUMBER

NCT06195865.

Does the use of acellular dermal matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review protocol

BACKGROUND

Breast cancer is the most common malignancy among women in the UK. Following mastectomy, reconstruction is now integral to the surgical management of breast cancer, of which implant-based reconstruction (IBBR) is the most common type. IBBR initially evolved from pre-pectoral to post-pectoral due to complications, but with developments in oncoplastic techniques and new implant technology, interest in pre-pectoral IBBR has increased. Many surgeons use acellular dermal matrices (ADM); however, there is little evidence in literature as to whether this improves surgical outcomes in terms of complications, failure and patient satisfaction. This review aims to assess the available evidence as to whether there is a difference in surgical outcomes for breast reconstructions using ADM versus non-use of ADM.

METHODS

A database search will be performed using Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Clinicaltrials.org. The search timeframe will be 10 years. Studies will be screened using inclusion and exclusion criteria and data extracted into a standardised spreadsheet. Risk of bias will be assessed. Screening, extraction and risk-of-bias assessments will be performed independently by two reviewers and discrepancies discussed and rectified. Data analysis and meta-analysis will be performed using Microsoft Excel and R software. Forest plots will be used for two-arm studies to calculate heterogeneity and p-value for overall effect.

DISCUSSION

With the renaissance of pre-pectoral IBBR, it is important that surgeons have adequate evidence available to assist operative decision-making. Assessing evidence in literature is important to help surgeons determine whether using ADM for IBBR is beneficial compared to non-use of ADM. This has potential impacts for patient complications, satisfaction and cost to healthcare trusts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2023 CRD42023389072.

Implant Based Breast Reconstruction Using a Titanium-Coated Polypropylene Mesh (TiLOOP® Bra): A Systematic Review and Meta-analysis

BACKGROUND

Implant-based breast reconstruction (IBBR) can be performed using a variety of biological and synthetic meshes. However, there has yet to be a consensus on the optimal mesh. This study investigates the safety and patient satisfaction of using TiLOOP® Bra in IBBR and compares its postoperative complication risk with that of porcine acellular dermal matrix (ADM) and SERAGYN® BR.

METHODS

The literature review was performed via PRISMA criteria, 23 studies met the inclusion criteria for the TiLOOP® Bra review, and 5 studies met the inclusion criteria for the meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS.

RESULTS

In 3175 breasts of 2685 patients that underwent IBBR using TiLOOP® Bra, rippling was observed as the most common complication, followed by seroma and capsular contracture. No significant difference in the overall complication rate between pre- and sub-pectoral IBBR using TiLOOP® Bra. However, the meta-analysis showed that the TiLOOP® Bra group had significantly lower odds of implant loss, seroma, wound dehiscence, and the need for reoperation or hospitalization than the ADM group. Additionally, the TiLOOP® Bra group had a significantly lower seroma rate compared to the SERAGYN® BR group, while the other outcome indicators were similar between the two groups.

CONCLUSION

TiLOOP® Bra has become increasingly popular in IBBR in recent years. This review and meta-analysis support the favorable safety profile of TiLOOP® Bra reported in the current literature. The meta-analysis revealed that TiLOOP® Bra has better safety than ADM and a comparable risk of complications compared to SERAGYN® BR. However, as most studies had low levels of evidence, further investigations are necessary.

LEVEL OF EVIDENCE III

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 .

Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

BACKGROUND

Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center.

METHODS

Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions.

RESULTS

A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months.

CONCLUSIONS

Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction

BACKGROUND

There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies.

METHODS

Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting.

RESULTS AND CONCLUSIONS

A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.

The effect of implant loss after immediate breast reconstruction on patient satisfaction with outcome and quality of life after five years - a case-control study

Several advantages have been suggested for immediate breast reconstruction (IBR); however, there is little scientific high-quality evidence confirming those advantages. Disadvantages of IBR, compared to delayed breast reconstruction (DBR), include an increased risk for complications, such as implant loss (prevalence 5-10% vs. 1%). Little is known on how women experience implant loss and how it affects patients' long-term satisfaction and quality of life (QoL). The primary aim of our study was to compare patient satisfaction and QoL of women with implant loss after IBR, with that of women with a successful IBR. Breast-Q, Body Esteem Scale for Adults and Adolescents (BESAA) and Hospital Anxiety and Depression Scale (HADS) were sent to women who had experienced implant loss during the last 10 years. Women of a similar age who were reconstructed, without complications, during the same period were controls. The results suggest that there might be a more permanent negative effect on satisfaction and QoL following implant loss. The proportion of possible cases of depression was higher among patients who had experienced implant loss. The findings could indicate that in patients with an elevated risk for implant loss, the possible benefits with IBR should be carefully balanced against the effects of implant loss.

Patient experience of implant loss after immediate breast reconstruction: An interpretative phenomenological analysis

Immediate breast reconstruction (IBR) is an integral part of modern breast cancer treatment. Our aim was to investigate patient experience with implant loss after IBR by using interpretative phenomenological analysis (IPA). We conducted semi-structured interviews with eight informants. We analyzed data according to the IPA flexible seven-stage process and four main themes were developed: immediate breast reconstruction as the indisputable choice, a difficult experience, an altered body: redefining normality, and trying to cope. The experience of implant loss appears to affect women for many years and might overshadow some of the benefits of IBR.

Biological and synthetic mesh assisted breast reconstruction procedures: Joint guidelines from the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons

These guidelines have been produced with the involvement of the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons. Recommendations have been derived after a review of published data regarding the use of acellular dermal matrix (ADM), biological and synthetic mesh in breast reconstruction. The guidelines represent a consensus opinion on the optimal management of patients having biological or synthetic mesh assisted breast reconstruction informed by peer-review publications. The Guidelines should be used to inform clinical decision making. Ultimately, members of the MDT remain responsible for the treatment of patients under their care.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

Salvaging the Unsalvageable: Negative Pressure Wound Therapy for Severe Infection of Prosthetic Breast Reconstruction

Background:

Severe infections of implant-based breast reconstruction are challenging to treat. Traditional management is removal of the implant with a further attempt at reconstruction months later once the infection has settled. This study evaluates an alternative management protocol using negative pressure wound therapy with instillation (NPWTi).

Methods:

Consecutive patients with severe peri-prosthetic infection following breast reconstruction were managed using the Implant Salvage Protocol: removal of the prosthesis with application of a NPWTi dressing, changed every 3 days until a negative culture was obtained. A new prosthesis was then placed in the pocket. Data were collected on patient demographics, microbiological, hospital/operative information, and overall success of salvage. Descriptive statistics were used for analysis.

Results:

In total, 30 breast prostheses in 28 patients were treated for severe peri-prosthetic infection. Twenty-five (83%) implants were salvaged. Mean time from initial reconstruction surgery to presentation was 49.5 days (median 23, range 7–420). Mean hospital stay was 11.5 days (median 12.0, range 6–22), mean number of returns to the operating theater was 3.7 (median 3.0, range 2–7), and mean number of days to negative culture was 5.2 (median 4.0, range 1–14). The most common organisms were methicillin-sensitive Staphylococcus aureus (n = 9) and Serratia marcescens (n = 4). Most had a tissue expander (n = 24, 80%) or implant (n = 5, 16.7%) placed at the completion of therapy. There was no record of capsular contracture nor recurrent infection during follow-up (mean 39.4 months, range 6–74 months).

Conclusion:

An estimated 83% of prosthetic breast reconstructions with severe infection were successfully salvaged using NPWTi.