Improved pocket control in immediate microsurgical breast reconstruction with simultaneous implant placement through the use of mesh

Long-Term Outcomes following Hybrid Breast Reconstruction

BACKGROUND

Hybrid breast reconstruction combines free tissue transfer with implant placement. Various mesh products have been successfully used to secure the implant position in these reconstructions. In this study, the authors investigate the impact of mesh type on long-term outcomes following hybrid breast reconstruction.

METHODS

A retrospective analysis of all patients with at least 24 months of follow-up after immediate bilateral prepectoral hybrid breast reconstruction was performed. Univariate and multivariable regression analyses were used to evaluate long-term outcomes and compare breasts reconstructed with polyglactin mesh versus acellular dermal matrix (ADM).

RESULTS

Thirty-nine patients (78 breasts) who underwent hybrid breast reconstruction with an average follow-up period of 50.4 months (range, 27 to 73 months) were included in the study. Postoperative complications included hematoma ( n = 2 [2.6%]), mastectomy skin necrosis ( n = 12 [15.4%]), and fat necrosis ( n = 6 [7.7%]). There were no instances of implant infection, implant exposure, or flap failure. Polyglactin mesh and ADM were used in 24 breasts and 54 breasts, respectively. Implant malposition and capsular contracture occurred more frequently in the polyglactin cohort leading to 10 (41.7%) instances of reoperation for implant replacement compared with only 1 (1.9%) in the ADM cohort ( P < 0.001). On multivariable regression analysis, polyglactin mesh was associated with a 36-fold greater probability of requiring implant replacement compared with ADM ( P = 0.006).

CONCLUSION

ADM (versus polyglactin mesh) is associated with lower rates of capsular contracture and implant malposition in the context of hybrid breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Analyzing mastectomy and reconstruction weight in immediate autologous breast reconstruction: A preliminary study

BACKGROUND

This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR).

METHOD

A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as "maintained" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare "downsized" or "upsized." Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively.

RESULTS

Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (β = -13, 95% confidence interval: -21 to -5.4; p = 0.001).

CONCLUSION

Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.

Outcome of modified fleur-de-lis latissimus dorsi myocutaneous flap for breast reconstruction

BACKGROUND

Reconstruction of breast following mastectomy is important in terms of rehabilitating patients of breast cancer. Numerous approaches have been used in the reconstruction process. A procedure that has gained interest of the patients is reconstruction of breast using the autologous form. Main objective of this study is to determine the outcomes of modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction.

METHODOLOGY

This is a retrospective case series which was conducted at the Department of Plastic Surgery, SIMS/Services Hospital, Lahore, from January 2020 till December 2022. 184 patients age 25-60 years and Females with a history of mastectomy, who had to undergo creation of breast shape using a tissue flap from another part of the body at the site of breast following mastectomy were included. All patients were subjected to standard procedure of breast reconstruction with latissimus dorsi flap using modified fleur-de-lis technique and postoperatively weekly assessment in the first month and then monthly until 3 months was carried out and outcome of the study was analysed.

RESULTS

The mean age and VAS score of the patients was 49.7 ± 9.17 and 6 ± 2.21, respectively. 57.1 % patients have DCIS, benign in 38 % patients and other tumours were present in 4.9 % patients. Immediate versus delayed reconstruction was done in 63.6 % versus 36.4 % patients respectively. Good aesthetic outcome was achieved in 80.3 % patients CONCLUSION: Modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction yielded a good aesthetic outcome in the majority of the patients.

Investigating the Severity of Complications following Mastectomy and Prepectoral Implant-Based versus Autologous Reconstruction

BACKGROUND

Several clinical studies have reported autologous breast reconstruction (ABR) to be associated with a higher postoperative complication rate; however, few have investigated the impact of reconstructive modality on complication severity. This study examines the impact of reconstructive modality on complication severity in a matched cohort of patients who underwent ABR versus implant-based breast reconstruction (IBR).

METHODS

A retrospective study of patients who underwent nipple-sparing mastectomy with immediate reconstruction was performed. Propensity score matching ensured adequate matching of patients who underwent ABR and staged prepectoral IBR, respectively. Patient demographics, breast measurements, and postoperative outcomes (including the incidence and severity of complications) were analyzed. Multivariable logistic regression analysis was performed. P < 0.05 was considered significant.

RESULTS

One hundred twenty-eight patients (214 breast reconstructions) were included for analysis (ABR, n = 64; IBR, n = 64). No difference in overall complication rate was noted ( P = 0.61). However, a significant association of IBR with major complications was noted ( P = 0.02). In contrast, minor complications were significantly more frequent following ABR ( P = 0.04).

CONCLUSIONS

Although the reconstructive modality did not appear to have an effect on the overall complication rate, it did significantly affect the severity of postoperative complications, with major and minor complications being associated with IBR and ABR, respectively. These findings are relevant to patient-centered decision-making, as they provide further granularity regarding postoperative complications and address the issue of complication severity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Hybrid Breast Reconstruction Following Mastectomy]

The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6 S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i. e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.

The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction

Shared decision-making gives patients greater autonomy in their healthcare decisions; however, decisions that result in negative outcomes may lead to decision regret. The complexity of reconstructive options makes post-mastectomy breast reconstruction particularly prone to decision regret. This study's purpose was to explore the relationship between breast reconstruction modalities and degree of postoperative decision regret. Patients who had undergone either implant-based or autologous breast reconstruction with a minimum of 12 months of follow-up were invited to complete the Decision Regret Scale and the BREAST-Q Satisfaction with Breasts module. The impact of reconstructive modality and occurrence of postoperative complications on decision regret and satisfaction with breasts was examined. Sixty-three patients completed the questionnaires-25 patients with implant-based reconstruction and 38 patients with autologous reconstruction. The average Decision Regret score was 84.6 ± 23.6; thirty-one patients experienced no decision regret. The average score for the BREAST-Q module was 81.9 ± 18.8. Neither satisfaction with breasts nor decision regret were impacted by the reconstructive modality. The occurrence of postoperative complications was strongly correlated with lower Decision Regret scores (91.6 vs. 74.6, p=0.004) but was not correlated with lower Satisfaction with Breasts scores (84.6 vs. 78.2, p=0.18). Patients had relatively low levels of decision regret and relatively high levels of satisfaction with breasts, irrespective of reconstructive modality. Having a postoperative complication led to significantly greater levels of decision regret without impacting satisfaction with breasts. Patients may benefit from additional preoperative education on possible complications to mitigate decision regret. LEVEL OF EVIDENCE IV: 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 .

TGF-β1 and CD68 immunoexpression in capsules formed by textured implants with and without mesh coverage: a study on female rats

PURPOSE

To evaluate fibrosis formation and number of macrophages in capsules formed around textured implants without and with mesh coverage.

METHODS

Fibrosis was analyzed through transforming growth factor-beta 1 (TGF-β1) immunomarker expression and the number of macrophages through CD68 percentage of cells in magnified field. Sixty female Wistar rats were distributed into two groups of 30 rats (unmeshed and meshed). Each group was then subdivided into two subgroups for postoperative evaluation after 30 and 90 days. The p value was adjusted by Bonferroni lower than 0.012.

RESULTS

No difference was observed in fibrosis between meshed and unmeshed groups (30 days p = 0.436; 90 days p = 0.079) and from 30 to 90 days in the unmeshed group (p = 0.426). The meshed group showed higher fibrosis on the 90th day (p = 0.001). The number of macrophages was similar between groups without and with mesh coverage (30 days p = 0.218; 90 days p = 0.044), and similar between subgroups 30 and 90 days (unmeshed p = 0.085; meshed p = 0.059).

CONCLUSIONS

In the meshed group, fibrosis formation was higher at 90 days and the mesh-covered implants produced capsules similar to microtextured ones when analyzing macrophages. Due to these characteristics, mesh coating did not seem to significantly affect the local fibrosis formation.

Histological evaluation of capsules formed by texturized silicone implants with and without polyester mesh coverage (Parietex®). A study on female rats

Purpose

To evaluate capsules formed by microtextured silicone implants with and without Parietex® mesh coverage histologically.

Methods

Sixty Wistar rats were divided in two groups (meshed and unmeshed). Each group was, then, divided into two subgroups for evaluation at 30 and 90 days. Capsules were analyzed based on hematoxylin and eosin (HE) and picrosirius staining.

Results

The number of fibroblasts, neutrophils and macrophages was similar among all subgroups. There was a higher lymphocyte reaction in the 30-day meshed group (p = 0.003). Giant cell reaction, granulation tissue and neoangiogenesis were similar among the subgroups. Synovial metaplasia was milder at 90-day in the unmeshed (p = 0.002) and meshed group (p < 0.001). Capsular thickness was significantly greater in the meshed samples (30-day p < 0.001 and 90-day p < 0.001). There was a similar amount of collagen types I and III in both groups.

Conclusions

The mesh-covered implants produced capsules similar to the microtextured ones when analyzing inflammatory variables. Synovial metaplasia was milder at 90 than at 30 days, and the capsular thickness was significantly greater in the meshed group. A similar amount of collagen types I and III was observed. Due to these characteristics, the mesh coverage did not seem to significantly affect the local inflammatory activity.

The Impact of Coagulopathy on Clinical Outcomes following Microsurgical Breast Reconstruction

SUMMARY

Autologous breast reconstruction has evolved considerably from pedicled muscle-based approaches to microsurgical perforator-based techniques. Patients with documented coagulopathy, however, remain a particularly challenging population. The authors present their experience in microsurgical breast reconstruction in patients with coagulopathy and discuss their treatment protocol. A prospectively maintained database was queried for patients with coagulopathy who underwent microsurgical breast reconstruction between 2016 and 2019. Information regarding patient demographics, type of coagulopathy, and anticoagulation regimen were retrieved, and clinical outcomes were investigated. Nineteen patients who underwent 34 microsurgical breast reconstructions with free abdominal flaps were included in the study. The most common coagulopathy was factor V Leiden [n = 7 (38.6 percent)]. Nine patients (47.4 percent) developed thrombotic complications (the majority occurring intraoperatively); notably, arterial and venous thrombosis in four (21.1 percent) and two patients (10.5 percent), respectively. Postoperative thrombotic complications included pulmonary embolism [n = 2 (10.5 percent)] and flap congestion secondary to venous thrombosis [two flaps (5.9 percent)]. Only one flap loss was observed secondary to delayed venous thrombosis on postoperative day 6 (2.9 percent). The anticoagulation regimen in the majority of patients consisted of intraoperative intravenous administration of heparin (2000 U [bolus]) followed by a 5-day heparin infusion at 500 U/hour [n = 10 (52.6 percent)]. The high rate of thrombotic complications in patients with coagulopathy who underwent microsurgical breast reconstruction is contrasted by a low flap loss rate. Although coagulopathy is a risk factor for thrombotic complications, successful microsurgical breast reconstruction is still possible in the majority of patients.

Evaluating the Quality of Cost-Effectiveness Literature in Breast Surgery: What Do We Do Well and How Can We Do Better? A Systematic Review

BACKGROUND

Surgical options for breast cancer are numerous and span multiple surgical disciplines. Decision analyses aid surgeons in making the most cost-effective choice, thus reducing health care expenditure while maximizing patient outcome. In this study, we aimed to evaluate existing breast surgery cost-effectiveness literature against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) validated scoring system.

METHODS

A PRISMA search was performed for cost-effectiveness within breast surgery. Articles were scored with CHEERS criteria on a 0-24 scale and qualitative data were collected. Subgroup analysis was performed comparing pre-CHEERS (published in 2013 or earlier) and post-CHEERS (published in 2014 or later) cohorts. Chi-squared analysis was performed to compare where studies lost points between cohorts.

RESULTS

Of 2279 articles screened, 46 articles were included. The average CHEERS score was 18.18. Points were most often lost for characterizing heterogeneity, followed by discount rate, incremental costs and outcomes, and abstract. Quality-adjusted life year was the most commonly used health outcome, with visual model or analog scales as the most commonly used measure of effectiveness obtained primarily from surgeons or physicians. Most articles characterized uncertainty by deterministic sensitivity analysis, followed by both deterministic and probabilistic, then probabilistic. Average CHEERS scores were similar between pre- and post-CHEERS cohorts (17.67 vs. 18.40, P > .05) There were several significant differences in where articles lost points between pre- and post-CHEERS cohorts.

DISCUSSION

In order to standardize the reporting of results, cost-effectiveness studies in breast surgery should adhere to the current CHEERS criteria and aim to better characterize heterogeneity in their analyses.

Abdominal Flap-based Breast Reconstruction versus Abdominoplasty: The Impact of Surgical Procedure on Scar Location

Supplemental Digital Content is available in the text.

Background:

Autologous breast reconstruction has been demonstrated to be associated with superior patient-reported outcomes, and hence is regarded as the gold standard reconstructive modality. A common drawback of this procedure, however, is related to a high abdominal scar. Recently, hybrid breast reconstruction (ie, the combination of autologous and implant-based reconstruction) was presented as an approach that would combine the benefits of both reconstructive modalities. In this study, we sought to assess abdominal aesthetic outcomes associated with this approach.

Methods:

Thirty-two blinded reviewers evaluated standardized pre- and postoperative abdominal images of patients following autologous reconstruction with free abdominal flap (Group 1; N = 10), hybrid reconstruction (Group 2; N = 5), and abdominoplasty (Group 3; N = 10). Aesthetic abdominal appearance, including overall result, scar position, skin redundancy, and lateral abdominal contour, was rated on a 5-point Likert scale and a comparative analysis was performed.

Results:

Hybrid reconstruction was associated with significantly lower abdominal scars compared with Group 1 (P = 0.01), nearing results of patients in Group 3 (P = 0.39). Significantly higher aesthetic ratings were ascribed to Groups 2 and 3 when compared with Group 1 (P < 0.001) with regard to scar positioning (P < 0.001), skin redundancy (P < 0.001), and lateral abdominal contour (P < 0.001). No significant difference in aesthetic ratings was noted between Groups 2 and 3.

Conclusions:

When applied to the appropriate patient population, hybrid breast reconstruction is a powerful method to achieve reconstructive goals while optimizing abdominal aesthetics. A significantly lower scar position was noted and higher abdominal aesthetic ratings were given following abdominoplasty and hybrid reconstruction compared with conventional abdominal flap-based reconstruction.

Breast Reconstruction with Free Abdominal Flaps Is Associated with Persistent Lower Extremity Venous Stasis

BACKGROUND

Previous work has demonstrated the occurrence of lower extremity venous stasis in the early postoperative period after breast reconstruction with free abdominal flaps. The authors investigated whether venous stasis persisted through the day of discharge, thus potentially exposing patients to an elevated risk of venous thromboembolism following discharge.

METHODS

Patients who underwent breast reconstruction with free abdominal flaps were enrolled prospectively and underwent duplex ultrasound of the common femoral vein at the following time points: preoperatively, postoperative day 1, and day of discharge. Parameters of interest included common femoral vein diameter, area, and maximum flow velocity.

RESULTS

Thirty patients with a mean age of 50.3 years (range, 29 to 70 years) underwent breast reconstruction with 52 free abdominal flaps. A significant increase in common femoral vein diameter (19.1 percent; p < 0.01) and area (46.8 percent; p < 0.01) correlated with a significant reduction in maximum flow velocity (-10.9 percent; p = 0.03) between baseline and postoperative day 1. These changes persisted through the day of discharge [common femoral vein diameter, 17.8 percent (p < 0.01); area, 46 percent (p < 0.01); and maximum flow velocity, -11.3 percent (p = 0.01)]. Venous parameters were not influenced by unilateral versus bilateral flap harvest (p = 0.48).

CONCLUSIONS

Postoperative lower extremity venous stasis following autologous breast reconstruction with free abdominal flaps seems to persist through the day of discharge. This finding may explain why patients remain at risk for venous thromboembolism after discharge. Although the authors' findings are at odds with current venous thromboembolism prophylaxis recommendations, additional studies are indicated to examine whether these findings translate into venous thromboembolism events.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Prosthetic Breast Reconstruction and Red Breast Syndrome: Demystification and a Review of the Literature

Supplemental Digital Content is available in the text.

Red breast syndrome (RBS) represents an inflammatory condition that rarely occurs in the setting of acellular dermal matrix use after prosthetic reconstruction. It is characterized by erythema or rubor that occurs directly over the ADM, and its appearance resembles that of a cellulitis. There have been many explanations with regard to etiology, but none have addressed the physiologic alterations leading to the onset and resolution of RBS. RBS is postulated to be the result of lymphatic disruption and is self-limiting. Resolution is postulated to be the result of angiolymphatic regeneration and the re-establishment of lymphatic flow within the mastectomy skin flap and the ADM, resulting in the clearance of inflammatory mediators responsible for the localized erythema.

Hybrid breast reconstruction-the best of both worlds

The two common reconstructive modalities following mastectomy include implant-based reconstruction and autologous reconstruction. While the majority of patients can be successfully treated with either one of these approaches, a subset of patients will benefit from a third reconstructive approach which combines implant-based and autologous reconstruction, i.e., hybrid reconstruction. Here, the authors discuss indications, surgical technique, results and additional reconstructive considerations of combining free abdominal tissue transfer with simultaneous implant placement. A reconstructive algorithm is presented.

Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross-over bypass: A case report

Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross-over bypass. A 54-year-old woman with a thrombosis of the left subclavian port-system in the medical history was elected for simultaneous bilateral breast reconstruction with ms-TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end-to-end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross-over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.