The Functional Impact of Breast Reconstruction: An Overview and Update

Understanding the Impacts of Surgical Drains on Postoperative Pain and Quality of Life

Background

Surgical drains are commonly used in breast surgery and breast reconstruction for seroma prevention. Although many surgeons are aware that surgical drains can cause considerable discomfort to patients, less is understood about the specific impacts of drains on postoperative pain and quality of life (QOL).

Methods

A cross-sectional survey was conducted among patients at our institution who had previously undergone mastectomy or breast reconstruction procedures to better understand patients' experiences with surgical drains. Patients were asked to report their attitudes toward a series of QOL statements and rate postoperative pain using numeric pain scales. Pair-wise analysis was used to identify predictors of responses.

Results

A total of 203 complete responses were recorded. Increased pain scale ratings for pain at the body wall, incision site, and drain entry site were significantly associated with drain duration at 2-3 weeks or longer (P < 0.05). Notably, 84.7% of patients reported that drains increased the difficulty of completing daily tasks. Most patients (66.0%) reported negative impacts on mood, and 37.0% reported apprehension toward undergoing future procedures that may require drains. Most patients (65.0%) also expressed that they would prefer to receive care from institutions that utilize improved alternatives to standard drains.

Conclusions

Surgical drains cause substantial discomfort to most patients and exert several negative impacts on QOL. In addition to limiting drain use wherever possible, innovations in technique and the development of alternatives to existing drains may offer patients a less painful, improved postoperative recovery experience.

Innovations in Nipple-areolar Complex Reconstruction: Evaluation of a New Prosthesis

Background

The reconstruction of the nipple-areola complex (NAC) is a crucial step for completing breast restoration with patient satisfaction. Surgical reconstruction or tattooing of the NAC may not be preferable or feasible for some patients. There is no universal method for NAC that is ideal for every patient or clinical situation. Various approaches often do not maintain projection over time. Over time, several techniques have been perfected, including the C-V flap, to improve and support projection for patients with bilateral implant-based reconstructions.

Methods

We used, for the first time, prosthetic devices for NAC reconstruction and examined the safety of these devices associated with ease of implantation and patient satisfaction levels using a survey conducted during a 1-year follow-up. We enrolled 20 individuals who opted for these NAC prostheses following unilateral or bilateral breast reconstruction and following NAC excision.

Results

Ninety percent of the participants expressed satisfaction or high satisfaction with the appearance and balance of the new NAC. The prosthetics enhanced the overall body self-image and self-regard of all the study participants. Except for 4 patients, there were no reports of skin adverse reactions, infections, or erosion.

Conclusions

Encouraged by these auspicious outcomes that indicate a significant rate of safety and satisfaction, we believe that this straightforward, noninvasive, affordable medical device deserves consideration as a reconstructive option for all patients seeking breast reconstruction, promoting full body integrity.

Outcomes of ADM-Assisted Implant-based Breast Reconstructions According to Division Types of the Pectoralis Major Muscle

BACKGROUND

In implant-based breast reconstruction (IBR), several surgical techniques are based on the implant insertion planes. Ideal location for breast implants has become a popular topic in IBRs because each technique has advantages and disadvantages. Herein, we report the outcomes of three different division types of the pectoralis muscle and suggest an algorithm for selecting the division types.

METHODS

Charts of patients who underwent IBRs between October 2017 and December 2020 were retrospectively reviewed. The patients were classified into three groups (prepectoral, high subpectoral, and subpectoral) according to the division types of the pectoralis muscle. Aesthetic outcomes were assessed in terms of animation deformity, rippling deformity, and visibility of the upper implant border.

RESULTS

Total 104 cases were included. 25, 38, and 41 were in the prepectoral, high-subpectoral, subpectoral IBR groups, respectively. Animation deformities frequently appeared in the subpectoral group. Nipple displacement was most prominent in the subpectoral group. Skin rippling at rest was mostly detected in the prepectoral group, whereas ripping during contraction was commonly observed in the subpectoral group. Visibility of upper border was more prominent in the prepectoral group than the other groups.

CONCLUSIONS

We propose an algorithm for selecting the division types of the pectoralis muscle. If the pectoralis muscle is thick, prepectoral plane is most preferred to avoid the animation deformity. In cases with thin pectoralis muscle, thickness of the mastectomy flap is considered next. If it is thicker than 1cm, prepectoral plane is better than the subpectoral plane; otherwise, high-subpectoral plane is preferable for better aesthetic outcomes.

LEVEL OF EVIDENCE V

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.

Quality of life in breast reconstruction: a comparison of lightweight and conventional breast implants

BACKGROUND

Due to the declining mortality rates of breast carcinoma and the rising incidence of risk-reducing mastectomies, enhancing the quality of life after breast reconstructions has become an increasingly important goal. The advantages of lightweight breast implants (B-Lite®) may significantly contribute to achieving this objective. This study aims to investigate whether lightweight implants are suitable for patients undergoing breast reconstruction and could improve the quality of life in comparison to conventional implants.

METHODS

In this study, we retrospectively analyzed 48 patients (38 implants in each group) who underwent implant-based breast reconstruction with either B-Lite® or conventional breast implants between 2019 and 2022 at the University Center for Plastic Surgery in Regensburg. As part of the postoperative follow-up, a clinical examination and a survey using the Breast-Q® questionnaire were conducted to evaluate the postoperative quality of life.

RESULTS

The implants used were similar in weight and shape. On average, the B-Lite® implants had a higher implant volume and patients in this group had a slightly higher BMI. Patients who received B-Lite® implants showed a significantly better result regarding the sensation of sensitivity in the surgical area and the scar formation also appeared to be more favorable. However, patients with B-Lite® implants perceived their implants as more uncomfortable than those with conventional breast implants. In other terms concerning quality of life, both groups appeared similar.

CONCLUSION

In summary, there are confounding factors that could influence the outcome of some aspects in this study, which could not be avoided due to the retrospective study design and the temporary suspension of B-Lite implants. Nevertheless, as the first of its kind, this study demonstrated that B-Lite implants could also be suitable for usage in breast reconstructions, thus providing an important foundation for further prospective studies to build upon.

The usefulness of artificial intelligence in breast reconstruction: a systematic review

BACKGROUND

Artificial Intelligence (AI) offers an approach to predictive modeling. The model learns to determine specific patterns of undesirable outcomes in a dataset. Therefore, a decision-making algorithm can be built based on these patterns to prevent negative results. This systematic review aimed to evaluate the usefulness of AI in breast reconstruction.

METHODS

A systematic review was conducted in August 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, EMBASE, SCOPUS, and Google Scholar online databases were queried to capture all publications studying the use of artificial intelligence in breast reconstruction.

RESULTS

A total of 23 studies were full text-screened after removing duplicates, and twelve articles fulfilled our inclusion criteria. The Machine Learning algorithms applied for neuropathic pain, lymphedema diagnosis, microvascular abdominal flap failure, donor site complications associated to muscle sparing Transverse Rectus Abdominis flap, surgical complications, financial toxicity, and patient-reported outcomes after breast surgery demonstrated that AI is a helpful tool to accurately predict patient results. In addition, one study used Computer Vision technology to assist in Deep Inferior Epigastric Perforator Artery detection for flap design, considerably reducing the preoperative time compared to manual identification.

CONCLUSIONS

In breast reconstruction, AI can help the surgeon by optimizing the perioperative patients' counseling to predict negative outcomes, allowing execution of timely interventions and reducing the postoperative burden, which leads to obtaining the most successful results and improving patient satisfaction.

Factors affecting upper limb functional recovery after mastectomy with immediate breast reconstruction: a prospective study

BACKGROUND

Little is known about the differences in postoperative shoulder function following two common approaches for immediate breast reconstruction (IBR): abdominal-based breast reconstruction and implant-based breast reconstruction (ABR and IMBR). It was hypothesized that postoperative upper limb function would differ between the ABR and IMBR due to incomplete detachment of the pectoral muscles.

PURPOSE

This study aimed to investigate the factors for shoulder function recovery post-IBR and compare recovery outcomes between ABR and IMBR.

METHODS

This single-center prospective follow-up study included 60 patients who underwent IBR for 4 months postoperatively. Patients were invited to complete functional measurements 1 and 4 months postoperatively. The primary outcome was improvement in upper limb disability based on the Q-DASH score. Secondary outcomes were functional shoulder recovery markers: shoulder flexibility, strength, movement accuracy, scapular alignment, body schema accuracy, and neuropathic pain. Repeated-measures analyzes of variance and linear regression were performed.

RESULTS

Within-group differences were found for most variables (p < .05) except for neuropathic pain (p = .929). However, there was no overall main group effect (p > .05). Multivariate regression analysis established significant models for ABR and IMBR (R2 = 0.430, p = .002 and R2 = 0.442, p < .001, respectively). However, the variables included in the model showed between-group differences.

CONCLUSION

Postoperative shoulder function was comparable between the two IBR approaches. However, different factors were associated with improved upper limb disability between ABR and IMBR. Acute rehabilitation focused on resolving muscle tightness and pain may help mitigate upper limb disabilities following IBR.Trial registration number: KCT 0006501.

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.

Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

PURPOSE

To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations.

METHODS

A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment.

RESULTS

1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years.

CONCLUSIONS

The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.

Immediate Prepectoral Breast Reconstruction Using an ADM with Smooth Round Implants – A Prospective Observational Cohort Study

Prepectoral breast reconstruction using acellular dermal matrices (ADMs) is well established and used in candidates for nipple/skin-sparing mastectomies; it is based on many different matrices and a great variability in breast implant selection. We describe our experience and clinical outcomes using Braxon® ADMs and smooth round breast implants. Females aged 18-80 years who underwent mastectomies with immediate prepectoral reconstruction between April 2019 and April 2021 were prospectively included. Complications were classified as mastectomy-related (hematoma, necrosis) or reconstruction-related (seroma, infection, red breast syndrome). Binary logistic regression analysis was performed to assess correlation between complication rate and selected variables, which were analyzed per breast with Kruskal-Wallis H test. Fifty-eight patients (102 breasts) received 45 bilateral and 12 unilateral procedures. Drains collected 485.9 cc [range: 100-1260] and were removed 15.7 days [range: 6-29] postoperatively. We report 41 complications (40.2%): 33 mastectomy-related, 8 reconstruction-related. Reoperation occurred in 14 patients: 7 wound debridement and revisions under local anesthesia; and 7 explantation. Implant loss rate was 6.8%. Mastectomy and reconstruction complications were not correlated with any variable. In conclusion, we found prepectoral reconstruction with Braxon® ADMs and smooth round implants to be associated with acceptable complication rates that are not influenced by any patient- or surgery-related factors. Drainage volume is comparable to other breast implant reconstructive techniques, but drains are left in place for longer.

Main factors determining the use of free MS-TRAM and DIEP flaps and comparing the results of breast reconstruction

This study aimed to compare the results of free MS-TRAM and DIEP-flap based on the volume of the transplant and the unique characteristics of blood flow in the tissues. The study included 83 patients, 42 in the MS-TRAM-flap reconstruction group and 41 in the DIEP-flap breast reconstruction group. In the MS-TRAM-flap group, 35 patients received delayed reconstruction, and 7 received one-stage breast reconstruction, including one case of bilateral transplantation. In the DIEP-flap group, 5 patients received one-stage reconstruction, and 36 received delayed reconstruction. Complications associated with the flap tissue were observed in 7 (16.67%) in the MS-TRAM-flap group and 8 (19.51%) cases in the DIEP-flap group. The total level of fat necrosis in MS-TRAM-flap was 7.14% (p=0.033), and in DIEP-flap, it was 9.75% (p=0.039) (2 patients had a substantial amount of fat necrosis, while 2 patients had a modest amount of focal fat necrosis). The number and diameter of perforators (including veins), as well as the transplant volume, are the primary determinants of whether to use a DIEP- or MS-TRAM-flap. DIEP-flap is preferred if there are 1-2 large artery perforators (≥1 mm) and tissue volume of 700-800 grams, while MS-TRAM-flap is used when the tissue volume is significant (>2/3 of standard TRAM-flap).

Novel Patient-Reported Outcome Measures for the Assessment of Patient Satisfaction and Health-Related Quality of Life Following Postmastectomy Breast Reconstruction

BACKGROUND

Patient-reported outcome measures (PROMs) have become an integral part of the evaluation of reconstruction surgery outcomes. However, there are limitations in current PROMs when it comes to the assessment of well-being during inpatient stay, patient perception of health, relationship with partner, and vitality (i.e., mood and ability to work and pursue hobbies, carry out daily tasks, and sleep) following breast reconstructive surgery. The aim was to develop a novel set of measures to compare patient satisfaction and health-related quality of life following different types of postmastectomy breast reconstruction.

METHODS

A novel questionnaire was created and refined through cognitive interviews with patients and expert feedback. A field test study was conducted, including patients who had undergone delayed postmastectomy breast reconstruction with implant, autologous tissue, or combination of implant and autologous tissue. Based on the results, confirmatory factor analysis and examination of reliability of the questionnaire were conducted. Results of patient responses were analyzed using Chi-square test, Kruskal-Wallis test, and Mann-Whitney U test.

RESULTS

Confirmatory factor analysis showed good model fit, and Cronbach's alpha indicated high internal consistency of the questionnaire. Besides that, patients with combination reconstruction reported significantly lower vitality than patients with implant and autologous reconstruction (p = 0.048).

CONCLUSIONS

This novel questionnaire expands the current knowledge base of postmastectomy breast reconstruction PROMs. Results of the field test study showed that combination reconstruction was associated with lower patient vitality than other reconstruction types.

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 .

Risk of Developing Breast Reconstruction Complications: A Machine-Learning Nomogram for Individualized Risk Estimation with and without Postmastectomy Radiation Therapy

BACKGROUND

The purpose of this study was to create a nomogram using machine learning models predicting risk of breast reconstruction complications with or without postmastectomy radiation therapy.

METHODS

Between 1997 and 2017, 1617 breast cancer patients undergoing mastectomy and breast reconstruction were analyzed. Those with autologous, tissue expander/implant, and single-stage direct-to-implant reconstruction were included. Postmastectomy radiation therapy was delivered either with three-dimensional conformal photon or proton therapy. Complication endpoints were defined based on surgical reintervention operative notes as infection/necrosis requiring débridement. For implant-based patients, complications were defined as capsular contracture requiring capsulotomy and implant failure. For each complication endpoint, least absolute shrinkage and selection operator-penalized regression was used to select the subset of predictors associated with the smallest prediction error from 10-fold cross-validation. Nomograms were built using the least absolute shrinkage and selection operator-selected predictors, and internal validation using cross-validation was performed.

RESULTS

Median follow-up was 6.6 years. Among 1617 patients, 23 percent underwent autologous reconstruction, 39 percent underwent direct-to-implant reconstruction, and 37 percent underwent tissue expander/implant reconstruction. Among 759 patients who received postmastectomy radiation therapy, 8.3 percent received proton-therapy to the chest wall and nodes and 43 percent received chest wall boost. Internal validation for each model showed an area under the receiver operating characteristic curve of 73 percent for infection, 75 percent for capsular contracture, 76 percent for absolute implant failure, and 68 percent for overall implant failure. Periareolar incisions and complete implant muscle coverage were found to be important predictors for infection and capsular contracture, respectively. In a multivariable analysis, we found that protons compared to no postmastectomy radiation therapy significantly increased capsular contracture risk (OR, 15.3; p < 0.001). This was higher than the effect of photons with electron boost versus no postmastectomy radiation therapy (OR, 2.5; p = 0.01).

CONCLUSION

Using machine learning, these nomograms provided prediction of postmastectomy breast reconstruction complications with and without radiation therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Real-time interactive digital healthcare system for post-operative breast cancer patients: study protocol for a randomized controlled trial

BACKGROUND

After receiving breast cancer surgery or reconstruction, shoulder dysfunctions including weakness, post-operative pain, shoulder joint instability, and limited range of motion (ROM) often occur. Due to limited ROM, patients may suffer difficulty in activities of daily living, and quality of life may be reduced. The objective of this study is to compare the effects on shoulder ROM of a real-time interactive digital healthcare system and brochure-based home rehabilitation program in post-operative breast cancer patients.

METHODS

This study is a prospective, multi-center, assessor-blinded randomized controlled trial. The study aims to recruit 100 breast cancer patients exhibiting limited shoulder ROM after undergoing axillary lymph node dissection or breast reconstruction following mastectomy. Patients will be randomly assigned to two groups for 8 weeks of rehabilitation: a digital healthcare system rehabilitation (intervention) group and a brochure-based rehabilitation (control) group. The primary outcome is the change in ROM of the affected shoulder between baseline and 12 weeks after enrollment. Secondary outcomes include pain in the affected shoulder, as measured using a numerical rating scale, functional outcomes (QuickDASH scores), and quality of life (FACT-B and EQ-5D-5L scores), all of which will be measured on enrollment and 4, 8, and 12 weeks thereafter.

DISCUSSION

This study will compare the effectiveness of a newly developed, augmented reality-based real-time interactive digital healthcare system with that of brochure-based home rehabilitation for improving the shoulder ROM, pain, functional outcomes, and quality of life of post-operative breast cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04316156 . Registered on 20 March 2020.

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

BACKGROUND

In both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend.

OBJECTIVE

The aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil.

METHODS

Online survey with physical therapists in both countries. We asked about physical therapists' clinical practice.

RESULTS

181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2-4 weeks ROM was unrestricted; at 1-3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities.

CONCLUSION

Only half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery.

The Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

 Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer.

METHODS

 Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I ² statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models.

RESULTS

 After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I ²= 4) after adjustment for publication bias. No other complications were statistically different between groups.

CONCLUSION

 In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.

Quality of Life and Early Functional Evaluation in Direct-to-Implant Breast Reconstruction After Mastectomy: A Comparative Study Between Prepectoral Versus Dual-Plane Reconstruction

BACKGROUND

In conservative mastectomies, in which the native skin envelope is preserved, positioning an implant in the submuscular plane commonly leads to functional consequences like upper limb movement impairment and animation phenomena. In recent years, however, a new conservative prepectoral breast reconstruction technique has been proposed, with demonstrated surgical safety and aesthetic effectiveness. The aim of our study was to explore and compare the functional and aesthetic outcomes of the prepectoral/acellular dermal matrix (ADM)-wrapped implant procedure versus subpectoral/ADM-assisted reconstruction.

PATIENTS AND METHODS

A retrospective nonrandomized comparative study of 94 patients (121 breasts) undergoing direct-to-implant breast reconstruction after skin-/nipple-sparing and skin reduction was conducted from February 2013 to October 2017. Fifty-five patients (group A) received subpectoral ADM-assisted reconstruction with dual-plane implant positioning, and 39 patients (group B) received prepectoral partially or totally ADM-wrapped implant reconstruction. Patients were allocated to either group A or B depending on the mastectomy flap thickness and vitality, as assessed clinically during the operation. Details of rehabilitation program, postoperative pain at 72 hours, postoperative analgesic therapies, demographic data, and complications were recorded. Upper limb function was assessed before and 1 month after surgery by a physiatrist according to a precise protocol. Patients were asked to fill in the BREAST-Q reconstruction questionnaire after surgery to evaluate outcomes.

RESULTS

Differences in upper limb function between groups, namely flexion (P = .03), abduction (P = .003), internal rotation (P = .02), and external rotation (P = .05), were statistically significant. Although most patients required postoperative rehabilitation, the individual rehabilitation intervention frequency was greater in the subpectoral group (91% in group A vs 74% in group B). There was also a significant difference in postoperative pain (within 72 hours), with less pain perceived in the prepectoral group (P = .01). Furthermore, prepectoral patients reported slightly better postoperative quality of life than subpectoral patients, particularly in the domains of sexual well-being (P = .005) and satisfaction with breast (P = .002).

CONCLUSION

In our case series, prepectoral implant positioning with partial or total ADM coverage led to less impairment of upper limb function in terms of flexion, abduction, and internal and external rotation, and also reduce the need for rehabilitation. Furthermore, as a result of the less invasive procedure, prepectoral patients had less immediate postoperative pain and were more satisfied with breast appearance.

Breast Tissue Expander With Radiofrequency Identification Port: Assessment of MRI Issues

OBJECTIVE. Breast tissue expanders with magnetic ports are MRI unsafe, preventing patients from benefiting from the diagnostic capabilities of MRI. A tissue expander was recently developed with a radiofrequency identification (RFID) port used for needle location and expansion that may be acceptable for a patient undergoing MRI. The purpose of this investigation was to evaluate MRI issues using standardized techniques and well-accepted methods for this tissue expander with RFID port. MATERIALS AND METHODS. The breast tissue expander with RFID port (Motiva Flora Tissue Expander, Establishment Labs) was assessed for magnetic field interactions (translational attraction and torque, 3 T), MRI-related heating (1.5 T/64 MHz and 3 T/128 MHz), artifacts (3 T), and functional changes associated with different MRI conditions (1.5 T/64 MHz and 3 T/128 MHz). RESULTS. Magnetic field interactions were minor (deflection angle of 2° and no torque) and thus will not pose a risk. At 1.5 T/64 MHz and 3 T/128 MHz, the highest temperature elevations (1.7°C and 1.9°C, respectively) were physiologically inconsequential. The tissue expander with RFID port exhibited relatively small artifacts on MRI. Exposures of the tissue expander with RFID port to different MRI conditions did not impact the ability to localize the RFID port or to read the electronic serial number. CONCLUSION. The findings indicated that this tissue expander with RFID port is "MR Conditional" for a patient referred for MRI at 1.5 T or 3 T. Importantly, the relatively small artifact associated with this implant offers potential advantages for patients undergoing MRI compared with tissue expanders that have magnetic ports that create substantial signal losses and distortions on MR images.

A prospective cohort study to analyze the interaction of tumor-to-breast volume in breast conservation therapy versus mastectomy with reconstruction

PURPOSE

We explored the impact of the relative volume of a tumor versus the entire breast on outcomes in patients undergoing breast conservation therapy (BCT) versus mastectomy and reconstruction (M + R). We hypothesized that there would be a threshold tumor:breast ratio (TBR) below which patient-reported outcomes (PRO) would favor BCT and above which would favor M + R.

METHODS

We conducted a prospective cohort study of patients with ductal carcinoma in situ (DCIS) or invasive breast cancers undergoing BCT or M + R. A prerequisite for inclusion, analysis of tumor and breast volumes was conducted from three-dimensional magnetic resonance imaging reconstructions to calculate the TBR. Three-dimensional photography was utilized to calculate pre- and postoperative volumes and assess symmetry. Oncologic, surgical, and patient-reported outcome data were obtained from relevant BREAST-Q modules administered pre- and postoperatively.

RESULTS

The BCT cohort had significantly smaller tumor volumes (p = 0.001) and lower TBRs (p = 0.001) than patients undergoing M + R overall. The M + R group, however, comprised a broader range of TBRs, characterized at lower values by patients opting for contralateral prophylactic mastectomy. Postoperative satisfaction with breasts, psychosocial, and sexual well-being scores were significantly higher in the BCT cohort, while physical well-being significantly favored the M + R cohort 480.2 ± 286.3 and 453.1 ± 392.7 days later, respectively.

CONCLUSIONS

Relative to BCT, M + R was used to manage a broad range of TBRs. The relative importance of oncologic and surgical risk reduction, symmetry, and number of procedures can vary considerably and may limit the utility of TBR as a guide for deciding between BCT and M + R. Clinical Trial StatementThis study was registered with clinicaltrials.gov as "A Prospective Trial to Assess Tumor:Breast Ratio and Patient Satisfaction Following Lumpectomy Versus Mastectomy With Reconstruction", Identifier: NCT02216136.

Comparing Prepectoral Versus Subpectoral Tissue Expander Placement Outcomes in Delayed-Immediate Autologous Breast Reconstruction

BACKGROUND

Delayed-immediate breast reconstruction has traditionally involved placement of tissue expanders (TE) in the subpectoral (SP) position. Development of acellular dermal matrices has renewed interest in the prepectoral (PP) pocket, which avoids extensive muscle manipulation. We compare complication rates between PP and SP TE placement in autologous delayed-immediate breast reconstruction.

METHODS

A retrospective chart review of patients undergoing autologous, delayed-immediate breast reconstruction at our institution (June 2009 to December 2018) was performed. Demographics, comorbidities, perioperative information, and complication incidence ≤12 months' follow-up were collected from first- and second-stage surgeries. Complications were modeled using univariable and multivariable binary logistic regressions.

RESULTS

A total of 89 patients met the inclusion criteria, and data from 125 breast reconstructions were evaluated. Complication rates following TE placement trended lower in the PP cohort (28.8% vs 37%, P = 0.34). Overall complication rates following autologous reconstruction were significantly lower for PP reconstructions (7.7% vs 23.3%, P = 0.02). Multivariable regression showed TE position (P = 0.01) was a significant predictor of ≥1 complication following autologous reconstruction. Time delay between first- and second-stage surgeries was greater for SP reconstructions (199.7 vs 324.8 days, P < 0.001). Postoperative drains were removed earlier in the PP cohort (8.6 vs 12.0 days, P < 0.001). Mean follow-up time was 331.3 days.

CONCLUSIONS

Prepectoral reconstruction in the delayed-immediate autologous reconstruction patient leads to significantly lower complication rates, shorter duration between first- and second-stage surgeries, and shorter times before removal of breast drains compared with SP reconstructions.

Refining the Latissimus Dorsi Flap: A Useful Tool to Salvage Complex Breast Defects

The latissimus dorsi flap has been used to reconstruct mastectomy defects for more than 100 years. It has remained relevant in breast reconstruction because of its consistent anatomy, robust vascular supply, congruent vector, and ability to cover large surface areas. With the evolution of oncologic and reconstructive techniques as well as improvements in prosthetic devices, however, this myocutaneous flap has largely fallen out of favor in primary breast reconstruction. Our experience demonstrates that the latissimus dorsi flap remains a versatile flap that may be tailored to reconstruct various oncologic breast defects and deformities in an expeditious fashion.

The musculoskeletal consequences of latissmus dorsi breast reconstruction in women following mastectomy for breast cancer

Introduction

Current evidence suggests that patients who have latissimus dorsi (LD) breast reconstruction following mastectomy for breast cancer can experience long-term shoulder dysfunction. However, as there is no standardised assessment or follow-up period within the literature, findings are conflicting. This research aimed to investigate the impact on daily living of immediate and delayed LD breast reconstruction in women following mastectomy for breast cancer.

Methods

Both qualitative and quantitative methods of enquiry were used. A focus group study explored the musculoskeletal consequences of surgery as perceived by the women (n = 15) and their healthcare professionals (n = 11). A questionnaire survey was administered (n = 159), including a range of outcome measures to quantify both the physical and psychosocial impact of LD breast reconstruction. Dyad interviews were also conducted in order to determine the impact of surgery on function and activities of daily living (ADL) from the woman’s perspective and that of her significant other (n = 8).

Results

The qualitative studies highlighted a lack of preparedness and unrealistic expectations regarding functional recovery among women and their significant others’. Post-surgery it was apparent that women weighed up reduced shoulder function against survival, demonstrating resilience in their approach to coping with this adaptive way of living. The survey identified low to moderate effect on the outcomes assessed (n = 159), however, node removal significantly impacted certain aspects of quality of life (p<0.05) and disability (p = 0.04).

Conclusions

Breast reconstruction using the LD had an impact on shoulder function and some ADL, which impacted not only on the women but also family and significant others. Despite the functional implications associated with surgery, findings would suggest that shoulder dysfunction is not their main concern. This work identified that women and their significant other require further information to clarify expectation regarding recovery, highlighting the changing priorities of women throughout their journey from diagnosis into long-term recovery.