Subcutaneous Implant-based Breast Reconstruction with Acellular Dermal Matrix/Mesh: A Systematic Review

Prepectoral Direct-to-Implant versus Staged Tissue Expander Breast Reconstruction: A Comparison of Complications

BACKGROUND

Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane.

METHODS

The authors retrospectively reviewed 348 patients who underwent 536 total immediate, prepectoral implant-based breast reconstructions between January of 2018 and December of 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients who underwent DTI versus TE reconstruction up to 1 year after surgery.

RESULTS

Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction ( P = 0.1813), respectively. The overall infection rate was 16.4% ( n = 57). DTI patients had a significantly greater incidence of wounds ( P < 0.0001), including minor ( P < 0.0011) and major wounds ( P < 0.0053). Significantly greater mastectomy resection weights were found for DTI patients who experienced any complication ( P < 0.0076), postoperative wounds ( P < 0.0001), and major wounds specifically ( P < 0.0035). Compared with medium-thickness acellular dermal matrix (ADM), extra thick ADM was associated with significantly increased rates of infection ( P < 0.0408) and wounds ( P < 0.0001).

CONCLUSIONS

Prepectoral DTI reconstruction in patients with adequate flap perfusion may have complication rates comparable to staged TE reconstruction, apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infection and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights who desire comparable or smaller implant volumes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

A Single-center Comparison of Surgical Outcomes following Prepectoral and Subpectoral Implant-based Breast Reconstruction

Background

Prepectoral implant placement continues to gain widespread acceptance as a safe and effective option for breast reconstruction. Current literature demonstrates comparable rates of complications and revisions between prepectoral and subpectoral placement; however, these studies are underpowered and lack long-term follow-up.

Methods

We performed a retrospective cohort study of patients who underwent immediate two-staged tissue expander or direct-to-implant breast reconstruction at a single center from January 2017 to March 2021. Cases were divided into prepectoral and subpectoral cohorts. The primary outcomes were postoperative complications, aesthetic deformities, and secondary revisions. Descriptive statistics and multivariable regression models were performed to compare the demographic characteristics and outcomes between the two cohorts.

Results

We identified 996 breasts (570 patients), which were divided into prepectoral (391 breasts) and subpectoral (605 breasts) cohorts. There was a higher rate of complications (P < 0.001) and aesthetic deformities (P = 0.02) with prepectoral breast reconstruction. Secondary revisions were comparable between the two cohorts. Multivariable regression analysis confirmed that prepectoral reconstruction was associated with an increased risk of complications (odds ratio 2.39, P < 0.001) and aesthetic deformities (odds ratio 1.62, P = 0.003).

Conclusions

This study evaluated outcomes in patients undergoing prepectoral or subpectoral breast reconstruction from a single center with long-term follow-up. Prepectoral placement was shown to have an inferior complication and aesthetic profile compared with subpectoral placement, with no difference in secondary revisions. These findings require validation with a well-designed randomized controlled trial to establish best practice for implant-based breast reconstruction.

Early Complications after Prepectoral Tissue Expander Placement in Breast Reconstruction with and without Acellular Dermal Matrix

BACKGROUND

Prepectoral breast reconstruction has become popularized with the concurrent use of acellular dermal matrix (ADM). The authors sought to compare 3-month postoperative complication rates and explantation rates for first-stage, tissue-expander-based, prepectoral breast reconstruction with and without the use of ADM.

METHODS

A single-institution retrospective chart review was performed to identify consecutive patients undergoing prepectoral tissue-expander-based breast reconstruction from August of 2020 to January of 2022. Chi-square tests were used to compare demographic categorical variables, and multiple variable regression models were used to identify variables associated with 3-month postoperative outcomes.

RESULTS

The authors enrolled 124 consecutive patients. Fifty-five patients (98 breasts) were included in the no-ADM cohort and 69 patients (98 breasts) were included in the ADM cohort. There were no statistically significant differences between the ADM and no-ADM cohorts with regard to 90-day postoperative outcomes. On multivariable analysis, there were no independent associations between seroma, hematoma, wound dehiscence, mastectomy skin flap necrosis, infection, unplanned return to the operating room, or explantation in the ADM and no-ADM groups after controlling for age, body mass index, history of diabetes, tobacco use, neoadjuvant chemotherapy, and postoperative radiotherapy.

CONCLUSIONS

The authors' results reveal no significant differences in odds of postoperative complications, unplanned return to the operating room, or explantation between the ADM and no-ADM cohorts. More studies are needed to evaluate the safety of prepectoral, tissue expander placement without ADM.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction

BACKGROUND

Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss.

METHODS

A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss.

RESULTS

The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016).

CONCLUSION

Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.

Acellular dermal matrix imaging features in breast reconstructive surgery: a pictorial review

Acellular dermal matrices (ADMs) are biological engineered tissues, which may provide an immunologically inert scaffold in breast reconstruction. Since the literature on imaging features of ADMs is limited, radiologists must be aware of the common imaging appearances of ADM, to differentiate normal conformation from residual or recurrent disease. Our purpose is to review the current role of ADMs in implant-based breast reconstruction, describing the normal imaging findings at ultrasound, mammography, and MRI also considering the possible changes over time. In this pictorial essay, we reviewed imaging features of ADMs described in the literature and we reported our experience in patients who underwent reconstructive surgery with human or animal ADM for newly diagnosed breast cancer.

National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction

BACKGROUND

Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020.

RESULTS

In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly increased rate of return to the operating room for any reason ( P < 0.001). When comparing the 2015 and 2020 ADM cohorts, the 2020 ADM cohort had a significantly higher rate of superficial infections. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wounds in patients receiving ADM.

CONCLUSIONS

ADM use in immediate breast reconstruction increased significantly from 2015 to 2020, likely reflecting national trends in increasing direct-to-implant and prepectoral breast reconstruction. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wound infections in the ADM cohort. Patients with ADM had a slight increased incidence of return to the operating room.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.

Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method.

METHODS

PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes.

RESULTS

A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1).

CONCLUSIONS

While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications.

Use of a biological scaffold in the cleavage area in complex revision breast augmentation: A surgical technique and case series

BACKGROUND

Bilateral breast augmentation has been the top surgical procedure performed worldwide by plastic surgeons for the past 5 years. Complex breast revision patients are challenging, with the cleavage area being one of the most difficult areas to navigate. We present a novel technique for using biological scaffolds in revision breast augmentation surgery.

METHODS

A step-by-step surgical technique is presented, combined with a series of 11 cases where either SurgiMend® acellular dermal matrix (ADM) or GalaFLEX mesh was used specifically in the medial cleavage area to correct a difficult to manage soft tissue contour deformity.

RESULTS

Eleven patients underwent revision breast augmentation with the use of the biological scaffolds in the medial cleavage area. The mean age was 43 years with a range of 29-68 years. All replacement breast implants were anatomical-shaped, medium profile, polyurethane-coated implants. GalaFLEX® mesh was used in six patients; five patients received SurgiMend® ADM. Mastopexy was performed in 8/11 patients. There were two complications in the same patient in this series, one emergency return to theater for bleeding and one minor scar revision.

CONCLUSIONS

Revision breast augmentation surgery includes a smorgasbord of options that can be used individually or in combination, such as full or partial capsulectomy, removal alone or replacement of the implant, change to the tissue plane of where the implant sits, mastopexy, and fat transfer. In addition to these recognized treatments, we would like to advocate the option of a biological scaffold for extra support of the cleavage area in complex revision cases.

Risk stratification in subpectoral to prepectoral pocket conversion to reduce post-reconstruction animation deformity

BACKGROUND

Animation deformity is a morbid complication that impacts women undergoing subpectoral implant-based breast reconstruction. Transferring implants from the subpectoral to prepectoral space, pocket conversion, can be performed to minimize this issue. While prior literature has evaluated outcomes associated with this procedure, we investigated the risk factors most commonly associated with post-conversion complications.

METHODS

We performed a retrospective cohort investigation of women undergoing prepectoral pocket conversion. Pre-conversion clinical characteristics and surgical complications (major and minor) were collected. Predictors for postoperative complications were identified using univariate and multivariate logistic regression models. Odds ratios (OR) and adjusted odds ratios (aOR) are presented with 95% confidence intervals, and p-values were assessed at α = 0.05.

RESULTS

A total of 34 patients (63 breasts) were included. Pocket conversion relieved animation deformity in all breasts. The overall rates of major and minor complications were 14.3% (n = 9/63) and 34.9% (n = 22/63), respectively, by mean follow-up of 11.1 months. After adjusting for confounders, pre-conversion implant rupture (OR= 6.00, CI= 0.99-34.58; aOR= 12.8, CI= 1.15-170.32) and duration of implant placement (OR=1.35, CI= 1.07-1.78; aOR= 1.1, CI= 1.00-1.21) were found to be significant predictors of major postoperative complications.

CONCLUSION

With a fairly inclusive patient population, this series provides data for improved risk stratification of patients considering conversion to relieve animation deformity. Interestingly, traditional risk factors (namely, body mass index and smoking status) were not significant predictors for postoperative complications, suggesting that conversion may be safe in high-risk patients. Such data support more informed preoperative counseling and wider application of this procedure.

A Comparative Study of Secondary Procedures after Subpectoral and Prepectoral Single-Stage Implant-Based Breast Reconstruction

BACKGROUND

Implant-based breast reconstruction (IBR) is the most commonly used procedure to reconstruct the breast after mastectomy. The advantages and disadvantages of subpectoral versus prepectoral implant placement remain a matter of debate. This study compares the need for secondary aesthetic procedures between prepectoral and subpectoral IBR.

METHODS

This is a retrospective cohort study of consecutive patients who underwent subpectoral or prepectoral IBR between 2015 and 2018 under a single surgeon at a tertiary breast unit. The primary endpoint was the number of secondary procedures performed to improve the aesthetic outcome. Secondary endpoints included the number of secondary procedures during the first year.

RESULTS

A total of 271 one-stage IBRs were performed (subpectoral, n = 128 in 74 patients; prepectoral, n = 143 in 84 patients). Overall, more patients required secondary procedures in the subpectoral group (36.5% versus 19%; P = 0.014), although through longer follow-up. The most common procedures were pocket revision and implant exchange [11.7% versus 3.5% ( P = 0.010); 11.7% versus 4.2% ( P = 0.021)], whereas fat grafting was similar between the two groups (46% versus 40.5%; P = 0.777). When adjusted for follow-up time, there was no significant difference in the number of secondary procedures undertaken in the subpectoral versus the prepectoral group (21% versus 16%, respectively; P = 0.288) at 1 year.

CONCLUSIONS

The requirement for secondary procedures at 1 year was not different between groups. The need for fat grafting was not increased following prepectoral IBR.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of Outcomes Following Prepectoral and Subpectoral Implants for Breast Reconstruction: Systematic Review and Meta-Analysis

(1) Background: Implant-based breast reconstruction following mastectomy helps to restore quality of life while aiming at providing optimal cosmetic outcomes. Both prepectoral (PP) and subpectoral (SP) breast implants are widely used to fulfill these objectives. It is, however, unclear which approach offers stronger postoperative benefits. (2) Methods: We performed a systematic review of the literature through PubMed, Cochrane Library, and ResearchGate, following the PRISMA guidelines. Quantitative analysis for postoperative pain as the primary outcome was conducted. Secondary outcomes included patient satisfaction and postoperative complications such as seroma, implant loss, skin necrosis, wound infection, and hematoma. (3) Results: Nine articles involving 1119 patients were retrieved. Our results suggested increased postoperative pain after SP implants and significantly higher rates of seroma following PP implants (p < 0.05). Patient satisfaction was found to be similar between the two groups; however, the heterogeneity of measurement tools did not allow us to pool these results. The rates of implant loss, skin necrosis, wound infection, and hematoma showed no significant differences between the two cohorts. (4) Conclusion: Our data suggest that both implant placements are safe and effective methods for breast reconstruction following mastectomy. However, homogeneity in outcome measurements would allow one to provide stronger statistical results.

Quality of life, pain of prepectoral and subpectoral implant-based breast reconstruction with a discussion on cost: A systematic review and meta-analysis

INTRODUCTION

Prepectoral implant-based breast reconstruction (PIBR) has regained popularity, despite decades-long preference for subpectoral implant placement. This paper aims to compare patient-reported outcomes (PRO) between prepectoral and subpectoral approaches to implant-based breast reconstruction (IBBR). The primary PRO was with the BREAST-Q, and postoperative pain scores, while the secondary outcomes were complication rates.

METHODS

A comprehensive literature search of the PubMed library was performed. All studies on patients undergoing IBBR after mastectomy that compared prepectoral to subpectoral placement and PROM or postoperative pain were included.

RESULTS

A total of 3789 unique studies of which 7 publications with 216 and 332 patients who received prepectoral and subpectoral implants, respectively, were included for meta-analysis. Patients with prepectoral implant placement had significantly higher satisfaction with the outcome (p = 0.03) and psychosocial well-being (p = 0.03) module scores. The pain was lower in patients with prepectoral implants on postoperative day 1 (p<0.01) and day 7 (p<0.01). The subgroup analysis of prepectoral breast implants showed that complete acellular dermal matrix coverage had lower rates of wound dehiscence (p<0.0001), but there were no significant differences in complications between one-stage and two-stage procedures.

CONCLUSION

Overall, patients with prepectoral implants reported higher BREAST-Q scores and lower postoperative pain and lower complications rates than patients with subpectoral implants. In appropriately selected patients, prepectoral implant placement with ADM coverage, be it the primary placement of an implant or placement of a tissue expander before definitive implant placement, should be the modality of choice in patients who choose IBBR. Further research should focus on patient selection, strategies to reduce cost and cost-benefit analysis of PIBR.

Risk Comparison Using Autologous Dermal Flap and Absorbable Breast Mesh on Patient Undergoing Subcutaneous Mastectomy with Immediate Breast Reconstruction

In patients with large breasts undergoing a subcutaneous mastectomy with immediate implant-based reconstruction, is necessary to perform a mastopexy. The combination of these procedures increases the complication rate. To reduce it, it is necessary to cover the lower pole of the implant. Our study aimed to compare the use of an autologous dermal flap and an absorbable breast mesh. A total of 64 patients without previous breast surgery were divided into 2 groups, each with 32 patients. In the 1st group, the implant was covered with an autologous caudally based dermal flap, sutured to the great pectoral muscle. In the 2nd group, the implant was covered with a fully absorbable breast mesh, fixed caudally in the inframammary fold and cranially to the great pectoral muscle. The incidence of complications, the aesthetic effect, and patient satisfaction were evaluated in a one-year follow-up. In the 1st group, there were 2 cases of seroma, 2 partial nipple-areola complex necrosis, 4 cases of dehiscence in the T-suture, and the malposition of the implant in 2 patients. In the 2nd group, there were 2 cases of seroma, 2 cases of T-junction dehiscence, and 1 case of full nipple-areola complex necrosis, which resulted in implant loss. There was no significant difference in patient satisfaction between the study groups. The dermal flap is more suitable for breasts with pronounced ptosis. The use of the synthetic mesh is suitable for smaller breasts, where the possible dermal flap would be too small to cover the implant. 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 .

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

Background

Various breast cancer reconstruction methods and novel surgical techniques include autologous or allogenic procedures, which can increase patient's quality of life and provide options when dealing with patients seen as challenging clinical scenarios.

Summary

Our aim was to review the current literature and present published evidence on innovative standards in whole breast reconstruction. Advances in flap monitoring or newly published data regarding neurotization in breast reconstruction, arm lymphedema management, breast implant-associated anaplastic large cell lymphoma reconstruction treatment, and robotic surgery with regard to radiotherapy define innovative standards in the breast reconstruction setting. The role of meshes/acellular dermal matrix and fat grafting as well as optimal sequencing of postmastectomy radiotherapy in autologous and alloplastic breast reconstruction appear highly debatable also in expert panel meetings rendering further clinical research including RCTs imperative.

Key Messages

There is an abundance of novel available techniques, which mandate further standardization, facilitating scientific evaluation in an attempt to help surgeons select tailored procedures for each patient with the goal to promote informed decision-making in breast reconstruction.

Direct-to-Implant Prepectoral Breast Reconstruction: Patient-Reported Outcomes

BACKGROUND

Direct-to-implant prepectoral breast reconstruction has recently experienced a resurgence in popularity because of its lower levels of postoperative pain and animation deformity. BREAST-Q, a well-validated patient-reported outcomes tool, was used to assess patient satisfaction and quality of life. The goal of this study was to assess patient-reported outcomes at 6-month and 1-year follow-up after direct-to-implant prepectoral breast reconstruction.

METHODS

Sixty-nine consented adult patients undergoing a total of 110 direct-to-implant, prepectoral, postmastectomy breast reconstructions completed BREAST-Q questionnaires immediately preoperatively, and at 6 and 12 months thereafter.

RESULTS

Mean breast satisfaction decreased nonsignificantly from 61.3 preoperatively to 58.6 at 12 months after reconstruction (p = 0.32). Psychosocial well-being improved nonsignificantly from 67.1 preoperatively to 71.1 at 12-month follow-up (p = 0.26). Physical well-being of the chest was insignificantly different, from 74.4 to 73.3 at 12-month follow-up (p = 0.62). Finally, sexual well-being similarly remained nonsignificantly changed from 60.2 preoperatively, to 59.1 at 12 months (p = 0.80). The use of acellular dermal matrix and postmastectomy radiotherapy did not have any significant effects on patient-reported outcomes. Through regression analysis, neoadjuvant chemotherapy, increased age, and incidence of rippling were found to negatively influence BREAST-Q results.

CONCLUSIONS

Patients who underwent direct-to-implant prepectoral breast reconstruction demonstrated an overall satisfaction with their outcomes. As prepectoral breast reconstruction continues to advance and grow in popularity, patient-reported outcomes such as those presented in this study become of paramount importance in practice.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Impact of demographic and perioperative risk factors on complication rates in skin-sparing/nipple-sparing mastectomy with implant-based reconstruction using titanized polypropylene mesh (TiLOOP® Bra)

BACKGROUND

Skin/nipple-sparing mastectomies (SSM/NSSM) have been reported to have acceptable complication rates and good aesthetic outcomes with high patient satisfaction. However, in this relatively young and rapidly expanding field of reconstructive plastic surgery, differences in perioperative management are noted between breast centers. Prospective studies of complication rates using a titanized polypropylene mesh (TiLOOP® Bra) are currently lacking.

METHODS

A prospective subgroup analysis was performed based on the data set of the prospective, single-arm, multicenter observational study (PRO-BRA). Early complication rates after skin/nipple-sparing mastectomy with implant-based immediate or secondary reconstruction using a titanized polypropylene mesh (TiLOOP® Bra) subpectorally were investigated in relation to demographic factors, as well as intra-and postoperative management. The subgroup consists of 258 patients. Complications were categorised into necrosis, infection, postoperative bleeding or hematoma, seroma, wound healing delays and R1-situations.

RESULTS

Early complication rates of SSM/NSSM using titanium-based meshes are comparable to complication-rates using ADM's. Logistic regression shows significantly higher risk for wound healing delays, necrosis and seroma with increasing BMI, abladat- and implant-weight (OR 1,17 -1,66, p-value < 0,001). Smokers have significantly higher necrosis rates (20.7%) compared to non-smokers (5.5%) (p-value = 0.002). Discharge with drainage results in a trend toward higher rates of wound healing complications.

CONCLUSION

The use of TiLOOP® Bra meshes was shown to have acceptable complication rates. Complication rates depend on certain demographic and intraoperative risk factors and should be considered in indications and information of patients.

Human Acellular Dermal Matrix (Epiflex®) in Immediate Implant-Based Breast Reconstruction after Skin- and Nipple-Sparing Mastectomy and Treatment of Capsular Fibrosis: Results of a Multicenter, Prospective, Observational NOGGO-AWOGyn Study

Background

Over the last decades, the number of acellular dermal matrix (ADM)-assisted implant-based breast reconstructions (IBBR) has substantially increased. However, there is still a lack of prospective data on complication rates.

Methods

We performed a non-interventional, multicenter, prospective cohort study to evaluate complication rates of a human ADM in patients undergoing an IBBR after skin- and nipple-sparing mastectomies. Patients with primary reconstruction (cohort A) and patients undergoing a secondary reconstruction after capsular fibrosis (cohort B) using the human ADM Epiflex® (DIZG gGmbH, Berlin, Germany) were enrolled in this study. Patients were followed-up for 12 months after surgery.

Results

Eighty-four eligible patients were included in this study of whom 28 women underwent a bilateral breast reconstruction, leading to 112 human ADM-assisted reconstructions in total (cohort A: 73, cohort B: 39). In 33.0% of the reconstructed breasts at least one of the complications of primary interest occurred, including implant loss 7.1%, seroma 15.2%; infection 5.4%, rash 8.0%, and Baker grade III/IV capsular fibrosis 2.7%, with no statistically significant differences between the cohorts. Previous radiation therapy was significantly associated with occurrence of any postoperative complication (OR 20.41; p value 0.027).

Conclusion

The rates of most complications were comparable to the rates reported for other ADMs with relatively low rates of capsular fibrosis and infections. The rate of seroma was increased in our study. Prior radiation therapy increased the risk of any postoperative complications. Therefore, the use of ADM in these patients should be considered carefully.

Assessing Postsurgical Outcomes with Prepectoral Breast Reconstruction: A Literature Review and Meta-analysis Update

Background:

Prepectoral implant-based breast reconstruction is an alternative to subpectoral/dual-plane reconstruction.

Methods:

This study examined outcomes of prepectoral reconstruction using a meta-analysis of data pooled with data from our previous review. Thirty studies were included.

Results:

Explantation, seroma, and infection were the most common complications with no animation deformity reported. Significantly lower odds of infection were observed with prepectoral compared with dual-plane reconstruction.

Conclusions:

Current literature suggests that prepectoral reconstruction may be associated with lower rates of postsurgical infections.

"Just Pulse it!" Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review

Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability. In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction

Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement.

Methods

To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021.

Results

Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791).

Conclusions

Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Prepectoral Versus Subpectoral Breast Reconstruction in High-Body Mass Index Patients

BACKGROUND

The effect of body mass index (BMI) on complication rates in prepectoral implant-based breast reconstruction is not well established. The purpose of this study was to compare complication rates between different BMI groups in subpectoral and prepectoral reconstruction.

METHODS

A single-surgeon, 4-year, retrospective review was performed of consecutive prosthetic breast reconstructions. During this time, the senior author's practice shifted from a subpectoral to prepectoral technique. Patients were stratified into BMI subgroups (<25, 25-35, and >35 kg/m2) and complication rates were analyzed. A survey was administered to blinded medical personnel and patients comparing esthetic results.

RESULTS

Implant-based reconstructions were performed in 195 patients (103 subpectoral and 92 prepectoral). No significant difference in major complication rate was observed between techniques. Among patients with BMI greater than 35 kg/m2, implant exposure occurred at a significantly higher rate in the prepectoral group (P = 0.04). In patients with BMI greater than 25 kg/m2, minor asymmetry was more prevalent with prepectoral reconstruction (12.3% vs 0%; P = 0.02). Regardless of technique, the odds of reoperation increased by 7% per point increase in BMI, although this did not reach statistical significance (P = 0.07; odds ratio, 1.07; 95% confidence interval, 0.99-1.15).A total of 66 survey responses were received. Physicians rated esthetic results more positively than patients did. Patients with a BMI of less than 25 kg/m2 were rated better than other BMI groups in nearly all categories. The position of submuscular reconstruction was rated significantly better than prepectoral.

CONCLUSIONS

There is a trend toward higher complication rates in prepectoral versus subpectoral breast reconstruction with increasing BMI. Nonetheless, the technique appears to be safe, with comparable clinical and cosmetic results.

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction

Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement.

METHODS

To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021.

RESULTS

Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791).

CONCLUSIONS

Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Microbiology of Implant-Based Breast Reconstruction Infections: A Systematic Review

BACKGROUND

Postsurgical complications have been an increasing concern for hospitals, particularly in light of payment reform. The costs to the health care system are increasing in light of Medicare penalties for readmissions for certain conditions. Surgical site infection following implant-based breast reconstruction (IBR) remains challenging. The rates of positive cultures and isolated microorganisms in IBR are unknown. This systematic review summarizes the reported microorganisms and positive culture rates in the existing literature.

METHODS

A systematic review was performed using the guidelines outlined in Preferred Reporting Items for Systematic Reviews and Meta-analyses. Articles were included if breast implant infection rates and culture results were reported. Further subgroup analysis of culture positive infections was performed.

RESULTS

A total of 25 studies were included, encompassing 25,177 IBR. Implant infections were reported in 1356 reconstructions (5.4%). Cultures were positive in 74.5% of infections. Gram-positive bacteria were the most common (68.6%), of which Staphylococcus species (51%) was the most isolated pathogen, followed by Pseudomonas. A subgroup analysis showed that early infections (63% vs 88%), radiotherapy (82% vs 93%), and acellular dermal matrix use (90% vs 100%) were associated with lower positive culture rates than their respective counterparts. Patients who received chemotherapy had higher positive culture results (94% vs 83%). Isolated microorganisms also varied among the subgroups.

CONCLUSIONS

This systematic review outlines reported microorganisms in IBR. Staphylococcus species and Pseudomonas were the most frequently reported microorganism. Negative cultures were reported in up to 25.5% of infections. Patients with early infections, radiotherapy, and acellular dermal matrix demonstrated higher negative culture rates. This review can help guide the use of empirical antimicrobial therapy in IBR.

Revision Breast Reconstruction with Prepectoral Pocket Conversion of Submuscular Breast Implants

BACKGROUND

Prepectoral reconstruction using prosthetic devices has demonstrated a notable increase in popularity and confers a number of advantages over subpectoral placement, including minimal animation, no pain secondary to muscle spasm, and less device displacement or malposition. As such, more women with implants in the dual-plane position are seeking a remedy for animation deformities, chronic pain caused by muscle spasm, and implant malposition. The purpose of this study was to review outcomes following the conversion from subpectoral to prepectoral implant placement.

METHODS

This was a retrospective review of 63 patients who underwent breast implant conversion from the subpectoral plane to the prepectoral plane from 2009 to 2019.

RESULTS

A total of 73 implant pocket conversions from subpectoral to prepectoral were performed on 41 women who met inclusion criteria for this study. The mean time interval from the initial subpectoral operation to the prepectoral conversion was 1608.4 days. The reasons cited for prepectoral conversion was animation deformity (87.8 percent), significant levels of pain related to the implant (34.1 percent), capsular contracture (26.8 percent), or asymmetries and implant displacements (9.8 percent); 7.8 percent of individuals continued to experience their presenting symptom after plane conversion. Rippling and wrinkling were noted in 19.5 percent of individuals and edge visibility was documented in 4.9 percent. Complication rates were low, and no patients experienced necrosis of the mastectomy flap or nipple-areola complex.

CONCLUSIONS

The use of prepectoral conversion for revision implant-based breast reconstruction successfully resolves animation deformity. This technique can be reliably and safely performed in a variety of patient demographics.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Sustainable Approach to Prepectoral Breast Reconstruction Using Meshed Acellular Dermal Matrix

Background:

Prepectoral implant-based breast reconstruction provides an alternative to submuscular reconstruction, but the increased acellular dermal matrix (ADM) required has the potential to lead to increased costs and decreased supply of this limited-resource material. We present a method for prepectoral reconstruction utilizing skin-graft meshing techniques to increase the surface area of usable ADM.

Methods:

Forty-four patients underwent this technique from February 2019 to February 2020. Patient characteristics, operative details, and outcomes, including complications and patient satisfaction utilizing the BREAST-Q, were analyzed. Cost analysis relative to projected cost of nonmeshed techniques was performed.

Results:

There were 20 unilateral and 24 bilateral procedures, for a total of 68 breast reconstructions. Mean age was 45.9 years (32–71). Mean implant volume was 485 cm³ (265–800), and one sheet of ADM was used for each breast with an average surface area of 161 cm². Median follow-up was 350 days (212–576). Minor complications included an infection treated with oral antibiotics. Major complications included one axillary hematoma and one delayed implant loss. One patient underwent revision for asymmetry. Mean BREAST-Q score was 47.4/60. Cost ranged from $4113 to 5025 per breast, compared with the projected $9125–18250 per breast for other techniques in the literature.

Conclusions:

In contrast to previously described uses of ADM in prepectoral reconstruction, meshing maximizes resource utilization by expanding the coverage of a single sheet. Early findings demonstrate minimal complications and high patient satisfaction, suggesting the approach has potential to provide the benefits of prepectoral reconstruction while responsibly preserving product availability and tempering healthcare costs.

Decreased postoperative pain and opioid use following prepectoral versus subpectoral breast reconstruction after mastectomy: A retrospective cohort study: Pain after pre- versus subpectoral reconstruction

BACKGROUND

Prepectoral (PP) breast reconstruction is now commonly performed and minimizes dissection of the pectoralis major muscle. Data are lacking comparing the immediate postoperative recovery of these patients as compared with traditional subpectoral (SP) breast reconstruction.

METHODS

From December 2015 to February 2017, 73 patients underwent PP prosthetic-based reconstruction at a single academic institution. PP cases were matched 1:1, by age and stage, to patients undergoing traditional SP reconstruction. Analysis of postoperative pain (visual analog scale) and opioid use (oral morphine equivalents, OME), was performed with both bi- and multivariate analyses. Additional outcomes explored included length of stay (LOS) and reconstructive intervention by plane of prosthetic reconstruction.

RESULTS

A total of 146 patients were included in the final cohort. PP reconstruction was associated with higher rates of direct-to-implant reconstruction (84.9% vs. 34.3%, p <0.001) and higher rates of initial prosthetic fill (401.53 mL vs. 280.88 mL, p<0.001). Patients undergoing PP reconstruction had significantly reduced postoperative pain (4.29 vs. 5.44, p<0.001) and in-hospital opioid use (62.63 mg OME vs. 98.84 mg OME, p = 0.03) compared with SP patients. This result remained in multivariate analysis for both pain (3.94 vs. 5.25, p<0.001) and opioid use (17.14 mg OME vs. 63.03 mg OME, p = 0.03). Additionally, patients undergoing PP reconstruction had significantly reduced overall LOS on multivariate analysis (21.36 vs. 26.28 h, p = 0.02).

CONCLUSION

Following mastectomy, PP breast reconstruction results in significantly reduced pain, opioid use, and hospital LOS compared with SP reconstruction.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Prepectoral 2-stage Breast Reconstruction with Carbon Dioxide Tissue Expansion

Roughly 80% of patients undergoing mastectomy in the United States opt for reconstruction with implants. The introduction of acellular dermal matrices has allowed for placement of breast prostheses in the prepectoral plane, while a new carbon dioxide tissue expander (TE) (AeroForm) allows for needle-free, patient-controlled expansion. These 2 novel technologies have ushered in a new patient-centered era of breast reconstruction, with the possibility of reducing patient morbidity for the first time in decades. We hypothesize that AeroForm expanders placed in the prepectoral plane reduce time to second-stage reconstruction, reduce the number of clinic visits, and have lower complications than traditional saline TEs.

Prepectoral Implant-Based Breast Reconstruction Using Meshed ADM

Prepectoral prosthetic breast reconstruction has been widely reassessed in recent years and is taking on an increasingly important role in the field of immediate breast reconstruction. We report here a case series of 32 patients who underwent nipple-sparing mastectomy for breast carcinoma and prepectoral breast reconstruction involving an acellular dermal matrix (ADM) treated by means of a skin-graft mesher in our hospital from January 2015 to March 2016. The indications for this type of reconstruction were body mass index (BMI) less than 30 kg/m²; no history of radiotherapy; no active smokers; moderate grade breast; and good viability of mastectomy flap: normal skin colour, active bleeding at the fresh cut edges, and thicker than 1 cm mastectomy flaps; the viability of lower thicknesses was ascertained by the fluorescent dye indocyanine green xenon-based imaging technology (4 patients). The mean age of the patients was 56.4 years (range: 39-77 years). Their mean BMI was 27.4 kg/m². Until the end of follow-up (mean: 17 months), major complications requiring reoperation occurred in 9% of patients and minor complications in 22% of patients. The mean of the 3 pain visual analogue scale scores taken in the first 24 hours after surgery was 1.8. Mean duration of hospital stay has been 2.2 days. Our complication rate was similar to those reported in other studies on prepectoral breast reconstruction featuring total ADM coverage of the implant.

Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes

PURPOSE

 This meta-analysis provides a large-scale comparison of prepectoral vs. subpectoral implant-based breast reconstruction, with primary outcomes of patient safety and efficacy.

METHODS

Literature review was performed via PRISMA criteria, 33 studies met inclusion criteria for prepectoral review and 13 studies met inclusion criteria for meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS.

RESULTS

In 4692 breasts of 3014 patients that underwent prepectoral breast reconstruction, rippling was observed as the most common complication, followed by seroma and skin flap necrosis. Meta-analysis demonstrated statistically significant decrease in odds of skin flap necrosis and capsular contracture in prepectoral groups compared to subpectoral groups. Odds of infection, seroma, and hematoma were equal between the two groups.

CONCLUSIONS

Prepectoral breast reconstruction has surged in popularity in recent years. This review and large-scale analysis corroborates current literature reporting a favorable safety profile with emphasis on patient selection. Variability in skin flap thickness and vascularity mandates thoughtful selection of patients whose overall health and intra-operative skin flap assessment can tolerate a muscle-sparing reconstruction.

Breast reconstruction using a laparoscopically harvested pedicled omental flap after endoscopic mastectomy for patients with breast cancer: an observational study of a minimally invasive method

BACKGROUND

Breast reconstruction is typically performed using autologous tissue from a laparoscopically harvested omental flap. Because open surgery and another abdominal wall incision for a subcutaneous tunnel cannot be avoided, minimal scars typically cannot be achieved. This study explored a minimally invasive method of pedicled omental flap breast reconstruction in which omentum harvesting, mastectomy, and subcutaneous tunnel establishing were performed laparoscopically and endoscopically, and large incisions on the thoracic and abdominal wall were unnecessary.

METHODS

Ten patients with breast cancer were enrolled. They underwent endoscopic subcutaneous mastectomy (ESM) and single-stage breast reconstruction using a laparoscopically harvested pedicled omental flap (LHPOF), which was pulled through a subcutaneous tunnel that was created under laparoscopic vision. The incisions made on the abdominal wall were no wider than 12 mm, and the thoracic wall incisions were no wider than 30 mm. Three of the patients had a prosthetic implant placed for reconstruction at the same time because of the large breast volume, and the omental flaps were used to cover the prostheses.

RESULTS

All patients underwent successful single-stage breast reconstruction surgery, and laparotomy was not required. Eight of the patients (80%) had satisfactory aesthetic results (five had excellent results and three had good results). The incisions at the thoracic wall and in the donor site area were short and hidden. The mean operation time was 367.6 min and the mean time for harvesting the omental flap was 62.9 min, similar to previous studies. The total mean blood loss was 37.0 mL. No serious donor-site complications occurred.

CONCLUSIONS

LHPOF breast reconstruction combined with ESM is minimally invasive, and satisfactory aesthetic results are achievable. In patients who undergo ESM combined with prosthetic implant reconstruction, the pedicled omental flap can be used to cover the prosthesis instead of using acellular dermal matrix.

Submuscular and Pre-Pectoral ADM Assisted Immediate Breast Reconstruction: A Literature Review

Background and objectives: Breast cancer treatment has deeply changed in the last fifty years. Acellular dermal matrices (ADMs) were introduced for breast reconstruction, with encouraging results, but with conflicting reports too. The present paper aims to summarize the current data on breast reconstruction using acellular dermal matrices. Materials and Methods: We reviewed the literature regarding the use of ADM-assisted implant-based breast reconstruction. Results: The main techniques were analyzed and described. Conclusions: Several authors have recently reported positive results. Nevertheless, an increased complications' rate has been reported by other authors. Higher cost compared to not-ADM-assisted breast reconstruction is another concern.

Negative Pressure Wound Therapy Reduces Wound Breakdown and Implant Loss in Prepectoral Breast Reconstruction

Background:

Single-use negative pressure wound therapy (NPWT) has been shown to encourage wound healing. It is often used when patient factors impair wound healing, or in more complex wounds, such as in implant-based breast reconstruction. We report the findings of a prospective cohort study comparing the use of NPWT with standard dressings in prepectoral breast reconstruction.

Methods:

A prospective database of implant-based reconstruction from a single institution was mined to identify patients who underwent prepectoral reconstruction. Patient demographics, operative data, surgical complications, and 90-day outcomes were compared between patients who had NPWT and those who had standard dressings.

Results:

Prepectoral implant-based breast reconstruction was performed on 307 breasts. NPWT dressings were used in 126 cases, with standard dressings used in 181 cases. Wound breakdown occurred in 10 cases after standard dressings versus 1 where NPWT was utilized. Of the standard dressing cases, only 3 implants were salvaged, while 7 cases led to implant loss. The 1 case of wound breakdown in the NPWT cohort settled with conservative measures. The cost of a reconstructive failure was £14,902, and the use of NPWT resulted in a cost savings of £426 per patient.

Conclusions:

The utilization of single-use NPWT reduces the rate of wound breakdown and implant loss in prepectoral implant-based reconstruction. In addition to the significant clinical benefits, this approach is cost-saving compared with standard dressings. These data suggest that prepectoral implant reconstruction should be considered as an indication for the use of NPWT.

The Pre-BRA (pre-pectoral Breast Reconstruction EvAluation) feasibility study: protocol for a mixed-methods IDEAL 2a/2b prospective cohort study to determine the safety and effectiveness of prepectoral implant-based breast reconstruction

INTRODUCTION

Implant-based breast reconstruction is the most commonly performed reconstructive technique worldwide. Subpectoral reconstruction with mesh is the current standard of care but new prepectoral techniques have recently been introduced. Prepectoral breast reconstruction (PPBR) may improve outcomes for patients but robust evaluation is required. Randomised clinical trials (RCTs) are ideally needed but the short-term safety of PPBR is yet to be established; the technique and its indications are evolving and it has yet to be adopted by a sufficient number of surgeons for an RCT to be feasible.The Pre-BRA study aims to determine the feasibility of using mixed-methods within an IDEAL 2a/2b (IDEAL, Idea-Development-Exploration-Assessment-Long-term) study to explore the short-term safety of PPBR and determine when the technique is sufficiently stable for evaluation in a pragmatic RCT.

METHODS AND ANALYSIS

Pre-BRA is an IDEAL stage 2a/2b prospective multicentre cohort study with embedded qualitative research.Consecutive patients electing to undergo immediate PPBR at participating centres will be invited to participate. Demographic, operative, oncology and complication data will be collected and patient-reported outcomes will be assessed at baseline, 3 and 18 months postoperatively. The primary safety endpoint will be implant loss at 3 months.Surgeons performing PPBR will be asked to complete questionnaires regarding their practice and report any modifications made to the procedure or learning arising from complications via free-text response fields on electronic case-report forms. Semistructured will explore surgeons' experiences in detail to identify emerging best practice. This will be fed back to participating surgeons to promote shared learning.The Pre-BRA study will aim to recruit 341 patients from 30 to 40 UK centres over a 12-month period. Recruitment will commence Spring 2019.

ETHICS AND DISSEMINATION

The study has full ethical approval from OXFORD-B South Central Committee Ref:19/SC/0129. Results will be presented at national and international meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN11898000; Pre-results.

The Impact of Device Innovation on Clinical Outcomes in Expander-based Breast Reconstruction

Staged expander-based breast reconstruction represents the most common reconstructive modality in the United States. The introduction of a novel tissue expander with an integrated drain (Sientra AlloX2) holds promise to further improve clinical outcomes.

Prepectoral Breast Reconstruction

Prepectoral breast reconstruction was first done in the early 1960s; however, while initial results were promising, high complication rates led surgeons to move toward submuscular implant placement. We soon came to find that submuscular implant placement was not without its own set of drawbacks. Surgeons have since revisited the efficacy of prepectoral breast reconstruction in light of new surgical and technological advances. Following these advancements, complication profiles for prepectoral breast reconstruction have drastically improved. Despite this change, surgeons recognize that prepectoral implant placement is not for everyone and patient selection is critical to success. As increasing numbers of these procedures continue to be done, we must now look to conduct direct comparisons between submuscular and prepectoral breast implant placement so that surgeons can make evidence-based decisions on patient selection and operative planning.

Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population

Background and objectives: Differences in patient anatomy and physiology exist between young and older patients undergoing breast reconstruction after mastectomy. Breast cancer has been described as being more aggressive, more likely to receive radiation, contralateral mastectomy, as well as bilateral reconstruction in young patients. Our purpose is to report long-term experience on two-staged implant-based breast reconstruction (IBR) in young females, with complication sub-analysis based on obesity and adjuvant radiation. Materials and Methods: Retrospective chart review of all consecutive young patients who underwent two-staged IBR at our institution, between 2000 and 2016, was performed. Patients between 15 and 40 years old with least 1-year follow-up were included. Univariate logistic regression models and receiver operating characteristic (ROC) curves were created. Results: Overall 594 breasts met our inclusion criteria. The mean age was 34 years, and the median follow-up was 29.6 months. Final IBR was achieved in 98% of breasts. Overall, 12% of breasts had complications, leading to explantations of 5% of the devices. Adjuvant radiation was followed by higher rates of total device explantations (p = 0.003), while obese patients had higher rates of total complications (p < 0.001). For each point increase in BMI, the odds of developing complications increased 8.1% (p < 0.001); the cutoff BMI to predict higher complications was 24.81 kg/m². Conclusions: This population demonstrates high successful IBR completion and low explantation rates. These data suggest that obese women and those with planned adjuvant radiation deserve special counseling about their higher risk of complications.

The bioengineered prosthetic breast reconstruction: advancements, evidence, and outcomes

Recent advancements in prosthetic breast reconstruction have provided the foundation for the bioengineered breast. These advancements include improved mastectomy techniques, autologous fat grafting, acellular dermal matrices (ADMs), and improved devices. Device-based breast reconstruction has evolved from subcutaneous, partial or total subpectoral, and now to prepectoral placement of devices. The evidence demonstrating the safety and efficacy of the bioengineered breast continues to increase. This manuscript will review the fundamental components of the bioengineered breast and provide an update of the current evidence.

Two-stage Prosthetic Prepectoral Breast Reconstruction: Comparing Tissue Expansion with Carbon Dioxide and Saline

Background

The AeroForm tissue expander is a carbon dioxide-filled breast tissue expander that allows gradual, needle-free expansion using a hand-held remote controller. This study evaluates 2-stage, prepectoral tissue expander-to-implant breast reconstruction with the carbon-dioxide tissue expanders and compares the outcomes to our recent experience with saline tissue expanders.

Methods

This was a retrospective study of consecutive patients from a single institution. The subjects consisted of women who underwent mastectomy and either immediate or delayed breast reconstruction with AeroForm or saline tissue expanders. Outcomes encompassed postoperative complications including mastectomy flap necrosis, infection requiring readmission and/or intravenous antibiotics, capsular contracture, hematoma, seroma, skin dehiscence, extrusion, premature explant, and loss of communication with the device (AeroForm) or rupture of the device (saline).

Results

This study evaluated 115 patients with 185 breast reconstructions. Of the 185 breast reconstructions, 74 (40%) utilized AeroForm tissue expanders and 111 (60%) utilized traditional saline tissue expanders. Treatment was successful in 100% and 94% in the AeroForm and saline groups, respectively (P = 0.025). The incidence of adverse events was greater in the saline group (45.9% versus 32.4%). Surgical-site infection occurred more commonly in the saline group (5.4% versus 0%). Full-thickness skin necrosis occurred at a significantly higher rate in the saline cohort as compared with AeroForm (5.4% versus 0%).

Conclusions

The use of AeroForm tissue expanders offers notable advantages for breast reconstruction. This device when employed in the prepectoral space may be associated with reduced infection rates and decreased utilization of healthcare and patient resources.

A systematic review of complications in prepectoral breast reconstruction

The use of implants for breast reconstruction began over four decades ago, with implants initially placed in the prepectoral space. Concerns arose regarding the high incidence of capsular contracture and complication rates. With the introduction of acellular dermal matrix (ADM), plastic surgeons are again considering the advantages of prepectoral implant placement. A systematic review was conducted to examine complication profiles in prepectoral breast reconstruction alone versus prepectoral with ADM or mesh. A systematic review of the PubMed database was performed from inception to March 2017 to identify literature on postmastectomy patients undergoing prepectoral breast reconstruction with and without ADM or mesh. Study characteristics, complication rates, and outcomes were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale, and complication profiles were analyzed using the random-effects model. Twenty-seven studies met criteria for inclusion out of 550 identified for review. For 1881 total breasts, the complication rate with ADM was 23.4%, while the rate without an additional implant material was 27.5%. The difference in the capsular contracture rate with and without ADM was 2.3% and 12.4%, respectively. The use of ADM in prepectoral breast reconstruction correlated with lower capsular contracture and overall complications rates; however, rates of implant loss, infection, and mastectomy flap necrosis were higher with the use of ADM. Results were variable across studies, and in general, the quality of evidence reported was low. Because the methodology for outcome assessment was inconsistent, there is a need for further investigation with comparative studies and standardized outcome reporting.

Surgical Outcomes of Prepectoral Versus Subpectoral Implant-based Breast Reconstruction in Young Women

Background:

Two-staged implant-based reconstruction (IBR) is the most common breast reconstructive modality. Recently, technological and surgical advances have encouraged surgeons to revisit prepectoral IBR. Data comparing prepectoral against subpectoral IBR in women under the age of 40 are lacking.

Methods:

Retrospective chart review of patients under the age of 40 years old, who underwent immediate 2-staged IBR at our institution, was performed. Patient’s demographics, clinical characteristics, operative details, and early surgical outcomes of prepectoral and subpectoral reconstruction were compared. Data with values of P < 0.05 were considered statistically significant.

Results:

Between 2012 and 2016, 100 patients (187 breasts) who underwent prepectoral and 69 patients (124 breasts) who underwent subpectoral IBR were included. Median follow-up was 17.9 and 17.5 months in the prepectoral and subpectoral groups, respectively. Total number of complications including both stages of reconstruction was 20 (10.7%) and 19 (15.3%) in the prepectoral and subpectoral groups, respectively (P = 0.227). Specific complications, including hematoma, seroma, skin flap necrosis, wound dehiscence, and breast infections, were not significantly different among groups. Ten (5.4%) devices, including implants and tissue expander, required explantation in the prepectoral group and 8 (6.5%) in the subpectoral group (P = 0.683). Explantation was most commonly due to infection (n = 14), and all of them occurred during the first stage (P < 0.001).

Conclusions:

Early complications and implant explantation rates are comparable among prepectoral and subpectoral breast reconstruction in women under 40 years old. Based on these results, we believe that prepectoral IBR is a safe, reliable, and promising reconstructive option.