A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer

Loss to follow-up after direct-to-implant breast reconstruction

Loss to follow-up is inevitable in retrospective cohort studies, and patients are lost to follow-up after direct-to-implant reconstruction despite annual follow-up recommendation. We analyzed more than 500 patients to analyze the rate of loss to follow-up to plastic surgery and to investigate the factors affecting it. A retrospective review of patients who underwent direct-to-implant reconstruction between July 2008 and August 2016 was performed. Loss to follow-up to plastic surgery was defined as a difference of ≥24 months between the total and plastic surgery follow-up. The rate of loss to follow-up and associated factors including patients' demographics, surgery-related variables, oncological data, and early and late complications were analyzed. Of 631 patients who underwent direct-to-implant reconstruction, 551 patients continued visiting the hospital for breast cancer-related treatment. Of the 527 patients who were eligible for the study, 157 patients (29.8%) were lost to plastic surgery follow-up. Surgery-related variables, early complications, cancer stage, and adjuvant therapies were not significantly different. Younger age was significantly associated with loss to follow-up in univariate analysis. However, logistic regression revealed that a long total follow-up period, distant metastasis, and absence of late elective complications were significant factors contributing to follow-up loss. Late elective complications such as malposition, capsular contracture, and mastectomy flap thinning were more common in the follow-up group (48%) than in the loss to follow-up group (22%). Follow-up loss after direct-to-implant reconstruction was not associated with specific demographic or surgery-related variables, and postoperative courses significantly affected the loss to follow-up.

Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation

Background Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction.

Methods We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018.

Results We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18).

Conclusion Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

[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.

Defining the Ideal Breast Reconstruction Procedure After Mastectomy From the Patient Perspective: A Retrospective Analysis

Background:

An increasing number of breast cancer patients undergo immediate or secondary breast reconstruction, but the ideal method in terms of patient satisfaction remains ambiguous. We compared the 3 most common breast reconstruction techniques to determine patient satisfaction and objective outcomes.

Methods:

Retrospective study of 184 patients with breast cancer who underwent a reconstructive procedure between 1993 and 2011 at our institution. Procedures evaluated were implant-based reconstruction (IBR) alone, latissimus dorsi (LD) flap reconstruction with/without implant, and deep inferior epigastric perforator (DIEP) free flap reconstruction. A retrospective patient satisfaction questionnaire was sent to all women. Twenty patients from each subgroup were matched to conduct a standardized objective assessment of the sensitivity of their reconstructed breast. A blinded photographic evaluation was also performed by 3 independent observers to assess the esthetic aspect and symmetry.

Results:

DIEP obtained significantly higher average scores regarding the esthetic outcome, immediate reconstruction impact, and overall score in the questionnaire evaluation. The IBR had the best results in the somatosensory evaluation, with DIEP scoring better than LD. DIEP received higher scores on average than LD for the criteria of size and symmetry in the esthetic evaluation. No statistically significant differences were observed between IBR and DIEP.

Conclusions:

Good results were reported overall for all breast reconstruction procedures, with more reserved scores for LD. The DIEP reconstruction appeared to be the most satisfactory and best experienced reconstruction method for patients, despite the complexity of the intervention. Clinicians should be encouraged to consider DIEP as the principal choice for breast reconstruction.

Influence of Triple-Negative versus Luminal A Breast Cancer Subtype on Choice of Autologous versus Implant-Based Delayed-Immediate Breast Reconstruction

BACKGROUND

 Triple-negative (TN) and luminal A breast cancer molecular subtypes have divergent clinical and prognostic characteristics for breast cancer patients. Our study aims to compare the reconstructive choice of these two groups from the time they receive a tissue expander (TE) to the time they complete autologous or implant-based breast reconstruction.

METHODS

 A total of 255 patients who underwent delayed-immediate breast reconstruction with TE placement from 2013 to 2017 diagnosed with either TN (n = 73) or luminal A (n = 182) invasive breast cancer subtype seen by two surgeons at a single institution were identified. Preference of autologous and implant-based reconstruction was analyzed, along with TE complications, race, age, body mass index (BMI), smoking, adjuvant therapy, and comorbidities.

RESULTS

 There was a significant difference in the choice of implant- or autologous-based reconstruction among these two groups (p < 0.05). A greater proportion of luminal A patients underwent implant-based reconstruction (63.47%) and a greater proportion of TN patients underwent autologous-based reconstruction (53.13%). With regard to TE outcomes, there was no significant difference between the two groups with regard to duration of TE placement by reconstructive type or TE surgical complications. Significantly, more TN patients underwent radiation therapy (p < 0.01) and neoadjuvant chemotherapy (p < 0.0001) than luminal A patients. BMI, comorbidities, radiation therapy, and overall TE complications were identified as predictive factors of patients electing for autologous reconstruction over implants.

CONCLUSION

 TN breast cancer patients mostly chose autologous-based reconstruction, while luminal A patients chose implant-based reconstruction. Both patient groups carried their TEs for similar duration with similar complication profile. Radiation therapy is likely a major factor in the decision for the type of delayed-immediate reconstruction among this population.

Assessing the Influence of Failed Implant Reconstruction on Patient Satisfaction and Decision Regret after Salvage Free-Flap Breast Reconstruction

BACKGROUND

 Free-flap breast reconstruction after failed implant reconstruction is associated with improved patient outcomes. How the level of satisfaction achieved compares between patients with and without previously failed implant reconstruction remains unknown. The aim of this study was to assess the influence of prior failed implant-based reconstruction on long-term patient-reported outcomes after free-flap breast reconstruction.

METHODS

 All patients undergoing free-flap breast reconstruction between 2015 and 2019 were identified. Patient satisfaction using the BREAST-Q and decisional regret using the Decision Regret Scale were compared between patients with and without a history of implant breast reconstruction.

RESULTS

 Overall, 207 patients were contacted and 131 completed the BREAST-Q and Decision Regret Scale. A total of 23 patients had a history of failed implant-based reconstruction requiring free-flap-flap salvage, most commonly due to infection (39.1%), chronic pain (34.8%), capsular contracture (26%), and implant malposition (26.1%). Following definitive free-flap reconstruction, patients with prior failed implant reconstruction had significantly lower BREAST-Q scores for satisfaction with breast (61.2 ± 16.7 vs. 70.4 ± 18.7; p = 0.04) and sexual well-being (38.5 ± 18.2 vs. 52.8 ± 24.7; p = 0.01) and reported higher decision regret (19.1 ± 18.6 vs. 9.6 ± 15.6, respectively). There were no significant differences for psychosocial well-being (p = 0.67), physical well-being (chest; p = 0.27), and physical well-being (abdomen; p = 0.91).

CONCLUSION

 A history of failed implant-based reconstruction is associated with reduced satisfaction and increased decision regret with the final reconstructive outcome. This data underscores the importance of appropriate patient selection at the initial consultation, and informed preoperative counseling regarding long-term outcomes in patients presenting for free-flap reconstruction after a failed implant-based reconstruction.

Rerouting of the pectoralis major muscle for breast animation deformity in sub-pectoral autologous breast reconstruction: A case report and review of the literature

INTRODUCTION

Breast animation deformity (BAD) is a known complication of sub-pectoral implant placement that is usually corrected by simply repositioning the implant to a pre-pectoral position. However, when this complication occurs in the case of a sub-pectorally placed free-flap, the solution becomes a lot less straightforward: repositioning of the flap carries the risk of possible damage to the pedicle. In order to avoid having to re-do the anastomoses we opted for a rerouting of the pectoralis major muscle around the vascular anastomoses.

PRESENTATION OF CASE

We present a 26-year old patient with unsatisfactory aesthetic outcomes of her bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. The flaps were placed sub-pectorally, in the already existing pocket that was created during her first breast reconstruction with silicone implants, resulting in severe BAD. Repositioning the free flap from the sub-pectoral to the pre-pectoral plane allowed for reinsertion of the pectoralis major muscle to its anatomical position without jeopardizing the vascular anastomoses. The patient was satisfied with the increased projection of the breasts.

DISCUSSION

Changing the plane from sub-pectoral to pre-pectoral remains the best treatment option for patients experiencing BAD. In combination with an acellular dermal matrix, this would have been a good option for our patient. However, when choosing to perform autologous breast reconstruction instead, our recommendation would be to always place the flap in the pre-pectoral plane to avoid BAD.

CONCLUSION

The report shows that the plane of a flap can be successfully changed without jeopardizing the pedicle of the flap.

An Individualized Patient-centric Approach and Evolution towards Total Autologous Free Flap Breast Reconstruction in an Academic Setting

Advances with newer perforator flaps and complex microsurgical techniques have enabled creative solutions in autologous breast reconstruction. For patients seeking total autologous breast reconstruction without the use of implants, body regions other than the abdomen have emerged to provide a substitute or additional donor tissue. In cases where abdominal perforator flaps are not possible (as with prior abdominoplasty), flaps taken from the lower back or thigh can be used. In situations of inadequate donor tissue in 1 body area, stacked multiple flap reconstruction is possible using donor tissue from multiple areas. In this article, we present our approach for individualizing treatment for breast reconstructive patients seeking to avoid permanent implants. We highlight how free perforator flap selection can not only serve to provide adequate tissue for body-appropriate breast reconstruction but may also be secondarily tailored to provide patient-specific aesthetic body contouring. Our preoperative patient counseling has evolved to involve flap selection based on clinical examination as well as advanced computed tomographic imaging of abdomen, thighs, and lower back. Decision to use 1 or more flaps is based on an assessment of whether the targeted body region(s) provide enough skin and fat for breast reconstruction, if the requisite perforator anatomy is available, and whether the effect of tissue procurement on their individualized aesthetic body contour is optimal.

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

BACKGROUND

Immediate implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK, but almost one in ten women experience implant loss and reconstructive failure after this technique. Little is known about how implant loss impacts on patients' quality of life. The first phase of the Loss of implant Breast Reconstruction (LiBRA) study aimed to use qualitative methods to explore women's experiences of implant loss and develop recommendations to improve care.

METHODS

Semistructured interviews were conducted with a purposive sample of women who experienced implant loss after immediate IBBR, performed for malignancy or risk reduction across six centres. Interviews explored decision-making regarding IBBR, and experiences of implant loss and support received. Thematic analysis was used to explore the qualitative interview data. Sampling, data collection and analysis were undertaken concurrently and iteratively until data saturation was achieved.

RESULTS

Twenty-four women were interviewed; 19 had surgery for malignancy and five for risk reduction. The median time between implant loss and interview was 42 (range 22-74) months. Ten women had undergone secondary reconstruction, two were awaiting surgery, and 12 had declined further reconstruction. Three key themes were identified: the need for accurate information about the risks and benefits of IBBR; the need for more information about 'early-warning' signs of postoperative problems, to empower women to seek help; and better support following implant loss.

CONCLUSION

Implant loss is a devastating event for many women. Better preoperative information and support, along with holistic patient-centred care when complications occur, may significantly improve the experience and outcome of care.

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.