1
|
Gabriel A, Maxwell GP, O'Rorke E, Harper JR. Performance of Human and Porcine Derived Acellular Dermal Matrices in Prepectoral Breast Reconstruction: A Long-term Clinicaland Histologic Evaluation. Aesthet Surg J 2024:sjae175. [PMID: 39344933 DOI: 10.1093/asj/sjae175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Human acellular dermal matrices (ADMs) remain the most used matrices in prosthetic breast reconstruction. However, the availability and cost of ADMs limit their use in prepectoral reconstruction-which requires large amounts of ADM-and alternative matrices are therefore being explored. OBJECTIVES The aim of this study was to demonstrate the safety and efficacy of human-porcine ADM constructs via clinical outcomes and histologic evidence of graft integration. METHODS Consecutive patients undergoing tissue-expander/implant reconstructions with human-porcine ADM constructs were included. Biopsies of both ADMs were obtained at expander/implant exchange and evaluated for cellularization, vascularization, and inflammation. Postoperative complications were retrieved from patient records. RESULTS Fifty-nine patients met the inclusion criteria. Mean [standard deviation] follow-up was 6.7 [0.56] years; minimum follow-up was 5 years. Any complication rate was 8.6%, including skin necrosis (6.9%), seroma (1.7%), expander/implant exposure (1.7%), and return to the operating room (2.6%). A total of 138 ADM biopsy specimens were obtained from 38 patients at expander/implant exchange. Histologic analyses revealed lower fibroblast infiltration and vascularization and higher inflammatory response in porcine vs human ADM specimens, consistent with published results in nonhuman primates. Despite these differences, there were no cases of graft rejection, capsular contracture, or expander/implant loss. CONCLUSIONS Porcine ADM performs clinically in a similar manner to human ADM, albeit with minor differences in cellular ingrowth and vascularization, suggesting that it may be an alternative to human ADM in prepectoral breast reconstruction. LEVEL OF EVIDENCE: 3
Collapse
|
2
|
Gunnarsson GL, Salzberg CA. Current status of pre- and retropectoral breast reconstructions worldwide: a narrative review. Gland Surg 2024; 13:1305-1314. [PMID: 39175699 PMCID: PMC11336793 DOI: 10.21037/gs-24-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 06/21/2024] [Indexed: 08/24/2024]
Abstract
Background and Objective Advances in breast cancer research and technology contribute to conservative ablative surgical approach with emphasis on reconstruction. The introduction of biologic membranes in breast surgery facilitates a one-stage implant reconstruction while the importance of the pectoralis major muscle involvement in the procedure becomes debatable. A subsequent increase in prepectoral implant placement procedures seems to close a cycle of innovations in implant-based breast reconstructions. This sparks a debate that calls for a critical review of existing literature considering that new challenges tend to arise along with new perspectives. The authors seek to scope the present status of prepectoral and subpectoral implant reconstruction worldwide, and answer recurring questions, including the novelty of presented innovations in the context of existing literature. Methods The article is based on a literature search in PubMed with the keywords "prepectoral" or "subpectoral" and "breast reconstruction", in addition to the authors' experience with a large number of patients. Key Content and Findings Recent studies focus on the comparative safety of prepectoral vs. subpectoral placement debating the use of biologic vs. non-biologic sheets and implant texture. There seems to be more emphasis on early post-operative safety of the procedures, rather than any long-term prospects of their comparison, up to this point. Skin and nipple sparing mastectomy (SSM/NSM) together with biological membranes have played a key role in current practice and cannot be overlooked. Conclusions After reading this paper, the reader should have a firm understanding of the key elements of implant-based breast reconstruction in historical context with emphasis on muscle planes and their pros and cons.
Collapse
|
3
|
Seitz AJ, MacKenzie EL, Edalatpour A, Janssen DA, Doubek WG, Afifi AM. Quantifying the Impact of Prepectoral Implant Conversion on Patient Satisfaction and Quality of Life. Plast Reconstr Surg 2024; 153:884e-894e. [PMID: 37335561 DOI: 10.1097/prs.0000000000010829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Conversion of subpectoral reconstruction to the prepectoral plane has been increasing in popularity. However, there is a paucity of research assessing patient-reported outcomes after this operation. The primary aim of this study was to examine patient-reported outcomes after conversion of implants from the subpectoral to prepectoral plane using the BREAST-Q. METHODS The authors retrospectively examined patients who underwent subpectoral-to-prepectoral implant conversion by three surgeons at two separate centers from 2017 through 2021. Patient demographics, primary indication for the conversion, surgical characteristics, postoperative outcomes, and BREAST-Q scores were obtained. RESULTS Sixty-eight breasts in 39 patients underwent implant conversion. The most common primary indications for implant conversion were chronic pain (41%), animation deformity (31%), and cosmetic concerns (28%). Average BREAST-Q scores improved significantly preoperatively to postoperatively in all the domains measured (satisfaction with breasts, satisfaction with implants, physical well-being, psychosocial well-being, and sexual well-being) ( P < 0.01). When examined by primary indication, all cohorts had significant preoperative to postoperative score improvement in satisfaction with breasts ( P < 0.001) and physical well-being ( P < 0.01) domains. Fifteen breasts (22%) developed postoperative complications, with implant loss in 9% of breasts. CONCLUSIONS Conversion of subpectoral implants to the prepectoral plane significantly improves BREAST-Q outcomes in all aspects, including patient satisfaction with breasts and implants, as well as psychosocial, physical, and sexual well-being. Implant conversion to the prepectoral plane is becoming the authors' primary solution for most patients with chronic pain, animation deformity, or cosmetic concerns after subpectoral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
Affiliation(s)
- Allison J Seitz
- From the Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health
| | - Ethan L MacKenzie
- From the Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health
| | - Armin Edalatpour
- From the Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health
| | | | | | - Ahmed M Afifi
- From the Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health
| |
Collapse
|
4
|
Parikh N, Gadiraju GK, Prospero M, Shen Y, Starr BF, Reiche E, Hyland CJ, Karinja SJ, Broyles JM. The Impact of Breast Implant Cohesivity on Rippling and Revision Procedures in 2-Stage Prepectoral Breast Reconstruction. Aesthet Surg J Open Forum 2024; 6:ojae028. [PMID: 38742237 PMCID: PMC11090255 DOI: 10.1093/asjof/ojae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
Background Rippling remains one of the most common complications following prepectoral implant-based reconstruction (IBR). Objectives The purpose of this study was to assess how implant cohesivity, a measure of elasticity and form stability, affects the incidence of rippling in prepectoral IBR. Methods We performed a retrospective cohort study of 2-stage prepectoral IBR performed between January 2020 and June 2022 at the Brigham and Women's Hospital and Dana-Farber Cancer Institute, comparing outcomes in patients who received Allergan Natrelle least cohesive, moderately cohesive, and most cohesive silicone gel implants. Outcomes of interest were rippling and reoperation for fat grafting. Results A total of 129 patients were identified, of whom 52 had the least cohesive implants, 24 had the moderately cohesive implants, and 53 patients had the most cohesive implants. The mean follow-up time was 463 (±220) days. A decreased incidence of rippling was seen with moderately cohesive (odds ratio [OR] 0.30, P < .05) and most cohesive (OR 0.39, P < .05) implants. Third stage reoperation for fat grafting was less frequent in patients with the most cohesive implant (OR 0.07, P < .05). In subgroup analyses, the patients with the most cohesive implant, who did not receive fat grafting at the time of initial implant placement, did not require reoperation for fat grafting (0%). Conclusions The use of highly cohesive implants in prepectoral IBR is associated with decreased rippling and fewer reoperations for fat grafting. Level of Evidence 3
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Justin M Broyles
- Corresponding Author: Dr Justin Michael Broyles, Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA. E-mail:
| |
Collapse
|
5
|
Rubenstein RN, Kim M, Plotsker EL, Chu JJ, Bell T, McGriff D, Allen R, Dayan JH, Stern CS, Coriddi M, Disa JJ, Mehrara BJ, Matros E, Nelson JA. Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction. Ann Surg Oncol 2024; 31:2766-2776. [PMID: 38245651 DOI: 10.1245/s10434-023-14861-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
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.
Collapse
Affiliation(s)
- Robyn N Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ethan L Plotsker
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jacqueline J Chu
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tajah Bell
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - De'von McGriff
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carrie S Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph J Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
6
|
Grzywacz VP, Lehrberg AV, Quinn TJ, Zureick AH, Sarvepalli N, Oliver LN, Dekhne NS, Dilworth JT. Breast Conserving Therapy for Patients With Prior Cosmetic Implant-Based Breast Augmentation: Outcomes and Comparison Against a Matched Cohort. Clin Breast Cancer 2024; 24:227-236. [PMID: 38185608 DOI: 10.1016/j.clbc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Controversy exists regarding potential increased toxic effects in patients with cosmetic implant-based augmentation (CIBA) who receive radiation therapy. We evaluated acute and chronic toxic effects associated with radiation therapy in women with prior CIBA treated with whole-breast irradiation (WBI) as part of breast conserving therapy (BCT) and compared these results against a cohort of patients without prior breast augmentation who received similar therapy. METHODS A retrospective review was performed to identify patients with a prior history of CIBA who subsequently underwent BCT with WBI. The control group consisted of consecutively treated patients without prior CIBA who also underwent BCT with WBI. Analyses included a comparison of baseline and treatment-associated factors between the augmentation and control groups, evaluation of toxic effects between both groups, and multivariable analysis of factors associated with the receipt of additional surgery following radiation. RESULTS Thirty-six patients with prior CIBA and 135 consecutively treated patients without CIBA were identified. Patients with prior CIBA were treated from 2006 through 2019, and patients without CIBA were treated from 2016 through 2019, though treatment characteristics and median follow-up time were similar between the two groups. Patients with prior CIBA were significantly less likely to experience acute moist desquamation (0% vs. 18%; P = .005). There were otherwise no statistically significant differences in acute (≤ 6 months) or chronic (> 6 months) toxic effects between the two groups. Rates of excellent/good chronic cosmetic outcome were 89% for the CIBA group and 97% in the control group (P = .094). On multivariable analysis, patients without prior CIBA (OR = 0.04; CI = 0.01-0.13; P < .001) and patients treated with moderately hypofractionated irradiation (OR = 0.08; CI = 0.02-0.23; P < .001) were significantly less likely to undergo additional surgery following receipt of WBI. Two patients experienced implant loss following radiation therapy. CONCLUSIONS WBI as part of BCT in patients with prior implant-based breast augmentation appears safe and is associated with favorable cosmetic outcomes. There was an increased need for additional surgery in patients with prior CIBA, but rates of acute and chronic toxic effects appeared similar to those in nonaugmented patients.
Collapse
Affiliation(s)
- Vincent P Grzywacz
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI
| | - Anna V Lehrberg
- Department of Surgery, Henry Ford Cancer Center, Detroit, MI
| | - Thomas J Quinn
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI
| | - Andrew H Zureick
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI
| | - Neha Sarvepalli
- Comprehensive Breast Care Center, William Beaumont University Hospital, Royal Oak, MI
| | - Lauren N Oliver
- Department of Plastic and Reconstructive Surgery, William Beaumont University Hospital, Royal Oak, MI
| | - Nayana S Dekhne
- Comprehensive Breast Care Center, William Beaumont University Hospital, Royal Oak, MI
| | - Joshua T Dilworth
- Department of Radiation Oncology, William Beaumont University Hospital, Royal Oak, MI.
| |
Collapse
|
7
|
Hassan AM, Asaad M, Morris N, Kumar S, Liu J, Mitchell MP, Shuck JW, Clemens MW, Butler CE, Selber JC. Subpectoral Implant Placement Is Not Protective against Postmastectomy Radiotherapy-Related Complications Compared to Prepectoral Placement. Plast Reconstr Surg 2024; 153:24-33. [PMID: 37010459 DOI: 10.1097/prs.0000000000010489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Postmastectomy radiotherapy (PMRT) is associated with altered cosmetic outcomes and higher complication rates in implant-based breast reconstruction (IBR). Conventional wisdom suggests that muscle coverage is somewhat protective against PMRT-related complications. In this study, the authors compared surgical outcomes in patients who underwent two-stage prepectoral versus subpectoral IBR in the setting of PMRT. METHODS The authors performed a retrospective cohort study of patients who underwent mastectomy and PMRT with two-stage IBR from 2016 to 2019. The primary outcome was breast-related complications, including device infection; the secondary outcome was device explantation. RESULTS The authors identified 179 reconstructions (101 prepectoral and 78 subpectoral) in 172 patients with a mean follow-up time of 39.7 ± 14.4 months. There were no differences between the prepectoral and subpectoral reconstructions in rates of breast-related complications (26.7% and 21.8%, respectively; P = 0.274), device infection (18.8% and 15.4%, respectively; P = 0.307), skin flap necrosis (5.0% and 1.3%, respectively; P = 0.232), or device explantation (20.8% and 14.1%, respectively; P = 0.117). In adjusted models, compared with prepectoral device placement, subpectoral device placement was not associated with a lower risk of breast-related complications [hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.41 to 1.36], device infection (HR, 0.73; 95% CI, 0.35 to 1.49), or device explantation (HR, 0.58; 95% CI, 0.28 to 1.19). CONCLUSIONS Device placement plane was not predictive of complication rates in IBR in the setting of PMRT. Two-stage prepectoral IBR provides safe long-term outcomes with acceptable postoperative complication rates comparable to those with subpectoral IBR, even in the setting of PMRT. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Abbas M Hassan
- From the Departments of Plastic and Reconstructive Surgery
| | - Malke Asaad
- From the Departments of Plastic and Reconstructive Surgery
| | | | | | - Jun Liu
- From the Departments of Plastic and Reconstructive Surgery
| | | | - John W Shuck
- From the Departments of Plastic and Reconstructive Surgery
| | - Mark W Clemens
- From the Departments of Plastic and Reconstructive Surgery
| | | | - Jesse C Selber
- From the Departments of Plastic and Reconstructive Surgery
| |
Collapse
|
8
|
Moyer HR, Sisson KM. The Effect of Early Cultures and Dual-port Expanders on Two-stage, Prepectoral Breast Reconstruction: The 25/25 Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5507. [PMID: 38196846 PMCID: PMC10773836 DOI: 10.1097/gox.0000000000005507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/06/2023] [Indexed: 01/11/2024]
Abstract
Background Two-stage tissue expander to implant surgery remains the predominant technique for breast reconstruction. Unfortunately, there is a high incidence of reconstruction failure which portends a financial and emotional burden. Most failures are related to postmastectomy skin flap necrosis and infection. Recently, a dual-port tissue expander was introduced to the market, and the authors hypothesize that early cultures from the peri-implant fluid will guide antibiotic treatment and decrease reconstruction failure. Methods This is a cohort study of 50 consecutive patients treated for breast cancer or genetic susceptibility via a two-stage, prepectoral technique. The first 25 patients (46 breasts) were treated with a variety of tissue expanders, and the subsequent 25 patients (47 breasts) received a dual-port expander. Routine cultures from the drain port were taken from the dual-port group at the second postoperative visit, and cultures were taken in the control group only when signs of infection were present. All other procedures and interventions were similar. Results Fifty patients, totaling 93 breasts, completed the study with a mean follow-up of 145 days. There were no statistically significant demographic or pathologic differences between groups. Fifteen tissue expanders were explanted in the control group and five in the dual-port cohort (32.6% versus 10.6%, P = 0.012). All bacteria in the control group failures were either methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis, whereas failures in the dual-port group varied. Conclusion Treatment of routine, early cultures from a dual-port expander led to a statistically significant decrease in tissue expander explantation.
Collapse
Affiliation(s)
- Hunter R. Moyer
- From the Monument Health Division of Plastic Surgery, Rapid City, S. Dak
| | | |
Collapse
|
9
|
Graziano FD, Plotsker EL, Rubenstein RN, Haglich K, Stern CS, Matros E, Nelson JA. National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction. Plast Reconstr Surg 2024; 153:25e-36e. [PMID: 37092982 PMCID: PMC11305089 DOI: 10.1097/prs.0000000000010575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
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.
Collapse
Affiliation(s)
- Francis D. Graziano
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ethan L. Plotsker
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robyn N. Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathryn Haglich
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carrie S. Stern
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
10
|
Brown OH, Danko D, Muret-Wagstaff SL, Emefiele J, Argüello-Angarita M, Baker NF, Losken A, Carlson G, Cheng A, Walsh M, Muralidharan VJ, Thompson PW. Close the GAPS: A Standardized Perioperative Protocol Reduces Breast Reconstruction Implant Infections. Plast Reconstr Surg 2023; 152:1175-1184. [PMID: 37010468 DOI: 10.1097/prs.0000000000010491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is a complex process with significant practice variability. Infections after IBBR are associated with higher rates of readmission, reoperation, and reconstructive failure. To reduce process variability and postoperative infections, the authors implemented an evidence-based, standardized protocol for IBBR. METHODS The protocol was applied to all patients undergoing IBBR at a single institution from December of 2019 to February of 2021. Intraoperative protocol adherence was recorded, and infection events were considered minor (managed with outpatient antibiotics) or major (managed with readmission or reoperation). A historic control group was retrospectively analyzed for comparison. RESULTS Sixty-nine patients (120 breasts) in the protocol group were compared with 159 patients (269 breasts) in the retrospective group. No differences were found in demographic characteristics, comorbidities, or type of reconstruction (expander versus implant). Intraoperative protocol adherence was 80.5% (SD, 13.9%). Overall infection rate was significantly lower in the protocol group versus controls (8.7% versus 17.0%; P < 0.05). When dichotomized, protocol patients had a lower rate of both minor (2.9% versus 5.7%; P = 0.99) and major (5.8% versus 11.3%; P = 0.09) infections, although this was not statistically significant. Rate of reconstructive failure secondary to infection was significantly lower in the protocol group (4.4% versus 8.8%; P < 0.05). Among protocol patients, those without infection had higher protocol adherence (81.5% versus 72.2%; P < 0.06), which neared statistical significance. CONCLUSION A standardized perioperative protocol for IBBR reduces process variability and significantly decreases rate of overall infections and reconstructive failure secondary to infection. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Owen H Brown
- From the Division of Plastic and Reconstructive Surgery
| | | | | | | | | | | | - Albert Losken
- From the Division of Plastic and Reconstructive Surgery
| | - Grant Carlson
- From the Division of Plastic and Reconstructive Surgery
| | - Angela Cheng
- From the Division of Plastic and Reconstructive Surgery
| | - Mark Walsh
- From the Division of Plastic and Reconstructive Surgery
| | | | | |
Collapse
|
11
|
Asaad M, Yu JZ, Tran JP, Liu J, O'Grady B, Clemens MW, Largo RD, Mericli AF, Schaverien M, Shuck J, Mitchell MP, Butler CE, Selber JC. Surgical and Patient-Reported Outcomes of 694 Two-Stage Prepectoral versus Subpectoral Breast Reconstructions. Plast Reconstr Surg 2023; 152:43S-54S. [PMID: 36877743 DOI: 10.1097/prs.0000000000010380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Opinion regarding the optimal plane for prosthetic device placement in breast reconstruction patients has evolved. The purpose of this study was to assess the differences in complication rates and patient satisfaction between patients who underwent prepectoral and subpectoral implant-based breast reconstruction (IBR). METHODS The authors conducted a retrospective cohort study of patients who underwent two-stage IBR at their institution from 2018 to 2019. Surgical and patient-reported outcomes were compared between patients who received a prepectoral versus a subpectoral tissue expander. RESULTS A total of 694 reconstructions in 481 patients were identified (83% prepectoral, 17% subpectoral). The mean body mass index was higher in the prepectoral group (27 versus 25 kg/m 2 , P = 0.001), whereas postoperative radiotherapy was more common in the subpectoral group (26% versus 14%, P = 0.001). The overall complication rate was very similar, with 29.3% in the prepectoral and 28.9% in the subpectoral group ( P = 0.887). Rates of individual complications were also similar between the two groups. A multiple-frailty model showed that device location was not associated with overall complications, infection, major complications, or device explantation. Mean scores for Satisfaction with the Breast, Psychosocial Well-Being, and Sexual Well-Being were similar between the two groups. Median time to permanent implant exchange was significantly longer in the subpectoral group (200 versus 150 days, P < 0.001). CONCLUSION Prepectoral breast reconstruction results in similar surgical outcomes and patient satisfaction compared with subpectoral IBR. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Malke Asaad
- From the Departments of Plastic and Reconstructive Surgery
| | - Jessie Z Yu
- From the Departments of Plastic and Reconstructive Surgery
| | - Jacquelynn P Tran
- From the Departments of Plastic and Reconstructive Surgery
- Department of Plastic Surgery, University of Texas Medical Branch
| | - Jun Liu
- From the Departments of Plastic and Reconstructive Surgery
| | | | - Mark W Clemens
- From the Departments of Plastic and Reconstructive Surgery
| | - Rene D Largo
- From the Departments of Plastic and Reconstructive Surgery
| | | | | | - John Shuck
- From the Departments of Plastic and Reconstructive Surgery
| | | | | | | |
Collapse
|
12
|
Vingan PS, Kim M, Rochlin D, Allen RJ, Nelson JA. Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose? Surg Oncol Clin N Am 2023; 32:761-776. [PMID: 37714642 DOI: 10.1016/j.soc.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.
Collapse
Affiliation(s)
- Perri S Vingan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Danielle Rochlin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| |
Collapse
|
13
|
Asaad M, Hassan AM, Morris N, Kumar S, Liu J, Butler CE, Selber JC. Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction. Aesthet Surg J 2023; 43:NP774-NP786. [PMID: 37265099 DOI: 10.1093/asj/sjad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established. OBJECTIVES The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane. METHODS We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation. RESULTS The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction. CONCLUSIONS Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes. LEVEL OF EVIDENCE: 4
Collapse
|
14
|
Guideline Awareness Disparities in Plastic Surgery: A Survey of American Society of Plastic Surgeons. Plast Reconstr Surg Glob Open 2022; 10:e4456. [PMID: 35958166 PMCID: PMC9362863 DOI: 10.1097/gox.0000000000004456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/08/2022] [Indexed: 12/05/2022]
Abstract
The American Society of Plastic Surgeons (ASPS) clinical practice guidelines were constructed to help direct evidence-based surgical management in plastic surgery. Societal member awareness of the recommendations for breast reconstruction has yet to be studied among ASPS members.
Collapse
|
15
|
Invited Discussion on: Usefulness of Incisional Negative-Pressure Wound Therapy for Decreasing Wound Complication Rate and Seroma Formation Following Pre-pectoral Breast Reconstruction. Aesthetic Plast Surg 2022; 46:642-643. [PMID: 35028680 DOI: 10.1007/s00266-021-02163-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 11/01/2022]
|
16
|
Liu J, Zheng X, Lin S, Han H, Xu C. A systematic review and meta-analysis on the prepectoral single-stage breast reconstruction. Support Care Cancer 2022; 30:5659-5668. [PMID: 35182228 DOI: 10.1007/s00520-022-06919-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of acellular dermal matrices (ADMs) and mesh reopened the possibility for the prepectoral single-stage breast reconstruction (PBR). The complications of single-stage breast reconstruction after PRB are controversial. We conducted a systematic review and meta-analysis of the impact of implant plane on single-stage breast reconstruction. Our aim was to evaluate the different postoperative complications between patients receiving prepectoral breast reconstruction and subpectoral breast reconstruction (SBR) on single-stage breast reconstruction. METHODS A comprehensive research on databases including PubMed, Embase, and Cochrane libraries was performed to retrieve literature evaluating the effect of implant plane on single-stage breast reconstruction from 2010 to 2020. All included studies were evaluated the complications after single-stage breast reconstruction. Only studies comparing patients who underwent prepectoral reconstruction with a control group who underwent subpectoral reconstruction were included. RESULTS A total of 13 studies were included in the meta-analysis, with a total of 1724 patients. In general, compared with SBR group, the PBR significantly reduced the risk of total complications (including seroma, hematoma, necrosis, wound dehiscence, infection, capsular contraction, implant loss/remove, and rippling) after single-stage breast reconstruction (OR: 0.54, 95% CI: 0.44-0.67, p < 0.001). Compared with the SBR group, the PBR had remarkably decreased capsular contracture (OR: 0.40, 95% CI: 0.27-0.58, p < 0.001) and postoperative infection (OR: 0.58, 95% CI: 0.36-0.95, p = 0.03). CONCLUSION The PBR is a safe single-stage breast reconstruction with fewer postoperative complications. It is an alternative surgical method for SBR.
Collapse
Affiliation(s)
- Jiameng Liu
- The Graduate School of Fujian Medical University, Fuzhou, 350000, Fujian Province, China.,Department of Breast Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - Xiaobin Zheng
- The Graduate School of Fujian Medical University, Fuzhou, 350000, Fujian Province, China.,Department of Radiotherapy, Fujian Medical University Cancer Hospital, Fuzhou, 350000, Fujian Province, China
| | - Shunguo Lin
- Department of Breast Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, 350001, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China.,Breast Cancer Institute, Fujian Medical University, Fuzhou, 350001, Fujian Province, China
| | - Hui Han
- Department of Breast Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, 350001, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China.,Breast Cancer Institute, Fujian Medical University, Fuzhou, 350001, Fujian Province, China
| | - Chunsen Xu
- Department of Breast Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou, 350001, Fujian Province, China. .,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China. .,Breast Cancer Institute, Fujian Medical University, Fuzhou, 350001, Fujian Province, China.
| |
Collapse
|