Obesity and Breast Reconstruction: Complications and Patient-Reported Outcomes in a Multicenter, Prospective Study

Surgical Management of Breast Capsular Contracture-A Multi-institutional Data Analysis of Risk Factors for Early Complications

BACKGROUND

Capsular contracture (CC) is a common complication following implant-based breast surgery, often requiring surgical intervention. Yet, little is known about risk factors and outcomes following CC surgery.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2021) to identify female patients diagnosed with CC and treated surgically. Outcomes of interest included the incidence of surgical and medical complications at 30-days, reoperations, and readmissions. Confounder-adjusted multivariable analyses were performed to establish risk factors.

RESULTS

5,057 patients with CC were identified (mean age: 55 ± 12 years and mean body mass index [BMI]: 26 ± 6 kg/m2). While 2,841 (65%) women underwent capsulectomy, capsulotomy was performed in 742 patients (15%). Implant removal and replacement were recorded in 1,160 (23%) and 315 (6.2%) cases, respectively. 319 (6.3%) patients experienced postoperative complications, with 155 (3.1%) reoperations and 99 (2.0%) readmissions. While surgical adverse events were recorded in 139 (2.7%) cases, 86 (1.7%) medical complications occurred during the 30 day follow-up. In multivariate analyses, increased BMI (OR: 1.04; p = 0.009), preoperative diagnosis of hypertension (OR: 1.48; p = 0.004), and inpatient setting (OR: 4.15; p < 0.001) were identified as risk factors of complication occurrence.

CONCLUSION

Based on 14 years of multi-institutional data, we calculated a net 30 day complication rate of 6.3% after the surgical treatment of CC. We identified higher BMI, hypertension, and inpatient setting as independent risk factors of postoperative complications. Plastic surgeons may wish to integrate these findings into their perioperative workflows, thus optimizing patient counseling and determining candidates' eligibility for CC surgery.

LEVEL OF EVIDENCE III

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A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction

BACKGROUND

Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps.

METHODS

For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis.

RESULTS

Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood.

CONCLUSION

Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction

BACKGROUND

 Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized.

METHODS

 A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey.

RESULTS

 In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05).

CONCLUSION

 The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.

Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity

BACKGROUND

 Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction.

METHODS

 A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m2) and Obese (BMI ≥ 30 kg/m2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups.

RESULTS

 Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time.

CONCLUSION

 The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.

The Effect of Obesity on Vaginoplasty Outcomes

BACKGROUND

Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques.

METHODS

A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected.

RESULTS

A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001).

CONCLUSIONS

Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study

Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.

Single-incision approach to aesthetic flat closure after bilateral mastectomy in morbidly obese patients

There has been a recent emphasis to offer women who forego reconstruction after mastectomy a surgically optimized flat closure (aesthetic flat closure (AFC)). While this certainly requires attention to details not previously considered by many surgeons, additional complexity is encountered in performing this procedure in the morbidly obese patient. Most of this additional complexity revolves around resecting additional subcutaneous tissue adjacent to the breast footprint. Here, we combine two previously described techniques, one to facilitate AFC in patients with normal body mass indices (BMIs) and another approach used to facilitate removal of excess lateral subcutaneous tissue after mastectomy in patients with elevated BMIs with our single-incision approach. The single-incision approach facilitates an expedited surgical procedure and resection of excess midline tissue with more reliably symmetrical incisions bilaterally . This report describes 10 consecutive morbidly obese patients who underwent mastectomy and AFC.

The Effects of Body Mass Index on Postoperative Complications in Patients Undergoing Autologous Free Flap Breast Reconstruction

BACKGROUND

 The prevalence of obesity in the United States exceeds 40%, yet perioperative effects of higher body mass index (BMI) in autologous breast reconstruction remain poorly studied. The purpose of this study was to investigate BMI's impact on postop complications in abdominal and gluteal-based autologous breast reconstruction.

METHODS

 We conducted a retrospective study using TriNetX, a health care database containing de-identified data from more than 250 million patients. Patients undergoing autologous breast reconstruction were identified by Current Procedural Terminology codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and 35 to 39.99 kg/m2. Outcomes of interest were defined by International Classification of Diseases,Tenth Revision (ICD-10) codes. A two-sample t-test was performed to compare incidence of postoperative complications between cohorts within 3 months of surgery. Patients with a BMI < 24.99 kg/m2 served as the control. Cohorts were balanced on age, race, and ethnicity.

RESULTS

 We identified 8,791 patients who underwent autologous breast reconstruction. Of those, 1,143 had a BMI < 24.99 kg/m2, 1,867 had a BMI of 25 to 29.99 kg/m2, 1,396 had a BMI of 30 to 34.99 kg/m2, and 559 had a BMI of 35 to 39.99 kg/m2. Patients with a BMI of 25 to 29.99 kg/m2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to 34.99 and 35 to 39.99 kg/m2 had a significantly increased risk of cellulitis, surgical site infection, need for debridement, wound dehiscence, and flap failure.

CONCLUSION

 Our study illustrates that there is an increased risk of postoperative complications associated with higher BMI classes. Understanding these data are imperative for providers to adequately stratify patients and guide the procedural decision-making.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy

BACKGROUND

Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy.

METHODS

A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected.

RESULTS

In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients.

CONCLUSIONS

There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study

BACKGROUND

Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue.

METHODS

A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups.

RESULTS

The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32).

CONCLUSION

FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.

Prepectoral Direct-To-Implant One-Stage Reconstruction With ADMs: Safety and Outcome in "Thin Patients"

BACKGROUND

Prepectoral direct-to-implant reconstruction with acellular dermal matrix (ADM) represents a safe, fast, and successful option in breast reconstruction in a selected cohort of patients. Nowadays, this procedure is considered challenging in thin. Meanwhile, his cohort has not been accurately analyzed yet.

METHODS

A single institution retrospective cohort study was performed between January 2019 and March 2023 in all women who underwent mastectomy. Biometrical and clinical data were recorded. Also, surgical technique, operating room (OR) time, mastectomy weights, implant choice, and acellular dermal matrix (ADM) types were properly noted. Postoperative complications represented the main topic: these were classified into early and late ones based on onset time. At least 12-month follow-up was required. A comparison between thin and ideal body mass index (BMI) populations was performed.

RESULTS

Early complications did not seem to differ between the 2 groups with 37.8% and 38.9% of women having at least 1 early complication in thin and ideal-weight women, respectively (P = .919). In univariable regression analysis, compared with women with a BMI of 22.1 to 25.0, women with a BMI ≤ 22.0 were associated with an increased risk of late complications of 2.84 (1.13-7.14). Specifically, thin women appeared to have a 3-fold increased risk (OR = 2.97, 95% CI 1.08-8.18) of ripples/wrinkles compared with women with ideal weight.

CONCLUSIONS

Prepectoral reconstruction with ADM in thin patients may be considered as safe as in standard BMI patients. Rippling may be more frequent, but, whenever needed, easy to correct with a few sessions of lipo-grafts.

LEVEL OF EVIDENCE

III.

Rates of major complications and flap loss for abdominally based breast reconstruction in obese patients are independent of WHO class of obesity

INTRODUCTION

Obesity is a risk factor for complications following autologous breast reconstruction. Little is known regarding outcomes based on the degree of obesity. This study compares breast reconstruction outcomes and complication rates for the three classes defined by the body mass index (BMI)-based WHO classification.

METHODS

The authors conducted a retrospective chart review identifying obese patients who underwent abdominally based breast reconstruction between January 2011 and January 2021. Patients were stratified by BMI class [class 1 (C1) = 30-34.99 kg/m2, class 2 (C2) = 35-39.99 kg/m2, and class 3 (C3) = 40 kg/m2 + ]. Outcomes were compared.

RESULTS

A total of 232 patients (395 flaps) were included with 138 patients were classified as C1, 68 patients as C2, and 26 patients as C3. Rates of any complication (80%) and at least one major complication (31%) did not vary significantly (P = 0.057, 0.185). Individual rates of 30-day readmission (18%) or reoperation (26%) did not vary significantly (P = 0.588 and 0.059). Rates of seroma (C1 = 15%, C2 = 16%, and C3 = 35%), hernia (C1 = 0%, C2 = 4%, and C3 = 8%), and incisional dehiscence (C1 = 30%, C2 = 44%, and C3 = 62%) were associated with significantly increased risk with higher classes of obesity (P < 0.05). The rate of flap failure did not vary significantly (P = 0.573).

CONCLUSION

The risk of major complications and total flap loss associated with abdominally based breast reconstruction does not differ between the classes of obesity. Although complication rates are high overall in the obese population, detrimental complications do not vary between the classes. Patients should be counseled regarding their individual risk without the need for arbitrary BMI cutoffs.

Short-Term Quality of Life after Autologous Compared with Alloplastic Breast Reconstruction: A Prospective Study

BACKGROUND

The aim of this prospective multicenter study was to evaluate whether autologous breast reconstruction (BR) leads to lower short-term quality of life (QoL) compared with alloplastic BR, due to the more physically demanding surgery and increased risk of severe complications of autologous BR.

METHODS

Changes in QoL after BR were measured in this prospective multicenter study using the BREAST-Q questionnaire, which was administered preoperatively and at 6 weeks and 6 months postoperatively. Characteristics and complications, classified according to Clavien-Dindo, were compared between alloplastic and autologous groups. Profile plots and generalized linear regression models were constructed to analyze the BREAST-Q subscales over time for both BR groups.

RESULTS

Preoperatively, women undergoing autologous BR scored lower on all BREAST-Q scales compared with women undergoing alloplastic BR, regardless of whether they underwent immediate or delayed BR. Women undergoing autologous BR scored higher at 6 weeks and 6 months postoperatively on the Satisfaction with Breasts ( P = 0.001), Psychosocial Well-Being ( P = 0.024), and Sexual Well-Being ( P = 0.007) subscales. Postoperative Physical Well-Being: Chest score was similar between the groups ( P = 0.533). Clavien-Dindo grade III or higher complications occurred more often among women in the autologous group (27% versus 12%, P = 0.042). Complications were not associated with worse BREAST-Q scores on any of the subscales.

CONCLUSIONS

In contrast to the authors' expectations, and despite the higher incidence of severe complications and lower preoperative breast satisfaction and QoL scores, women undergoing autologous BR had higher levels of breast satisfaction and psychosocial and sexual well-being, both at 6 weeks and 6 months after BR, compared with women undergoing alloplastic BR.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Surgical Outcomes of Autologous Breast Reconstruction in Low Body Mass Index Patients: Beyond the Standard DIEP Flap

BACKGROUND

Autologous breast reconstruction provides higher satisfaction than implant-based reconstruction in women with low body mass index (BMI). However, the accepted standard of microvascular breast reconstruction, the deep inferior epigastric perforator (DIEP) flap, can be challenging to achieve due to the paucity of adnominal bulk in these patients. This study compared operative outcomes in women with BMI less than 23.5 following reconstruction after one of three free flap methods: the DIEP flap, alternative flaps (ie, lumbar artery perforator flap or profounda artery perforator flap), and stacked flaps.

METHODS

A retrospective study was conducted on thin patients (BMI <23.5) who underwent autologous breast reconstruction between 2010 and 2021 by two senior authors (N.T.H. and S.S.T.) at a single institution. One hundred fifteen patients were divided into three reconstructive groups. Flap weights, complication rates, secondary revisions, and fat grafting in each group were then compared.

RESULTS

The success rate in all three groups was 100%, with only one partial flap loss in the stacked group. There was a significant difference in overall minor complications and donor complications among the three groups, with alternative flaps experiencing the most. All three groups had similar incidences of recipient breast complications, medical complications, need for secondary revisions, and amount of fat grafted.

CONCLUSIONS

Autologous breast reconstruction in low BMI patients yields successful and durable results. This study shows that predictable results in the thin patient population can be obtained via alternate autologous methods beyond the standard DIEP flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose?

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.

Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction

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

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

A Scoping Review of the Application of BREAST-Q in Surgical Research

Background

Collection of patient-reported outcome (PRO) data can facilitate cost-effective, evidence-based, and patient-centered care. The BREAST-Q has become the gold standard tool to measure PRO data in breast surgery. The last review of its application indicated that it was underutilized. Considering the evolution in breast surgery, the purpose of this study was to perform a scoping review of BREAST-Q application since 2015 and identify emerging trends and potential persistent gaps to guide patient-centered practice and future research in breast surgery.

Methods

We performed an electronic literature review to identify publications published in English that used the BREAST-Q to assess patient outcomes. We excluded validation studies, review papers, conference abstracts, discussions, comments, and/or responses to previously published papers.

Results

We identified 270 studies that met our inclusion criteria. Specific data was extracted to examine the evolution of the BREAST-Q application and examine clinical trends and research gaps.

Discussion

Despite a significant increase in BREAST-Q studies, gaps in the understanding of the patient experience remain. The BREAST-Q is uniquely designed to measure quality of life and satisfaction with outcome and care. The prospective collection of center-specific data for every type of breast surgery will generate important information for the provision of patient-centered and evidence-based care.

Oncoplastic and reconstructive breast surgery

This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.

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.

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

Longitudinal analysis of long-term outcomes of abdominal flap-based microsurgical reconstruction and two-stage prosthetic reconstruction

Two-stage tissue expander/implant (TE/I) and deep inferior epigastric perforator (DIEP) flaps are the two main pillars of breast reconstruction. This study aimed to conduct a longitudinal analysis of long-term outcomes after immediate DIEP- and TE/I-based reconstruction. This retrospective cohort study included patients with breast cancer who underwent immediate DIEP- or TE/I-based reconstruction between 2012 and 2017. The cumulative incidence of major complications, defined as unplanned reoperation/readmission due to complications, was analyzed by the reconstruction modality and its independent association. In total, 1,474 cases (1,162 TE/I and 312 DIEP cases) were analyzed, with a median follow-up of 58 months. The 5-year cumulative incidence of major complications was significantly higher in the TE/I group (10.3% vs. 4.7%). On the multivariable analyses, the use of DIEP flap was associated with a significantly reduced risk of major complications compared to that of TE/I. A more prominent association was observed in the analysis of patients who received adjuvant radiotherapy. Restricting analysis to those who received adjuvant chemotherapy revealed no differences between the two groups. The rate of reoperation/readmission for improving aesthetic outcomes was similar in the two groups. Long-term risks for unexpected reoperation/readmission may differ between DIEP- and TE/I-based immediate reconstruction.

The mirror viewing experience of women undergoing a mastectomy: An integrative review

AIMS

To appraise the current literature on the mirror viewing experience of women undergoing a mastectomy.

DESIGN

Whittemore and Knafl's approach to integrative reviews, Braun and Clarke's thematic analysis, and PRISMA guidelines were utilized for this review.

DATA SOURCES

A systematic search of primary peer-reviewed articles from April 2012 to 2022 was conducted using PubMed, CINAHL, Academic Search Complete and Google Scholar databases.

REVIEW METHODS

Eighteen studies met the inclusion criteria (15 qualitative and 3 quantitative) and were appraised using the Johns Hopkins evidence-based practice appraisal instrument.

RESULTS

Five themes describing the mirror viewing experience were revealed: Mirror viewing motives, mirror viewing preparedness, mirror viewing experience, mirror comfort/avoidance and women's mirror viewing recommendations.

CONCLUSION

The review findings were found to align with Freysteinson's Neurocognitive Mirror Viewing Model highlighting the occurrence of short-term memory disruptions and an autonomic nervous system response that can lead women to experience a flight/fright or faint response, mirror trauma and mirror avoidance when looking at themselves in the mirror after a mastectomy.

IMPACT

Women reported feeling unprepared to look at themselves in the mirror, with some experiencing shock and emotional distress, which led to mirror avoidance behaviours as a way to cope with their new body image. Nursing interventions aimed at improving women's mirror viewing experiences may help mitigate this autonomic nervous system response and minimize mirror trauma and mirror avoidance. Preparing women to view themselves in the mirror for the first time may help reduce psychological distress and body image disturbances in women undergoing a mastectomy.

NO PATIENT OR PUBLIC CONTRIBUTION

This integrative review did not involve patient or public contributions. The authors reviewed currently published peer-reviewed literature in writing this manuscript.

Satisfaction With Information Predicts Satisfaction With Outcome and Surgeon in Black and Hispanic Patients Undergoing Breast Reconstruction

BACKGROUND

Racial disparities in American healthcare contribute to worse outcomes among minority patients. Minority patients undergoing breast reconstruction are more likely to report dissatisfaction with their reconstruction process as compared with White patients, yet there is limited research exploring contributory factors. This study investigates which process-of-care, clinical, and surgical variables are most strongly correlated with Black and Hispanic patients' reported satisfaction.

METHODS

A retrospective review of all patients who underwent postmastectomy breast reconstruction at a single academic center from 2015 to 2021 was performed. Patients were included for analysis if they identified as Black or Hispanic and completed preoperative, less than 1-year postoperative, and 1- to 3-year postoperative BREAST-Q surveys. At both postoperative time points, the association between satisfaction with outcome and surgeon and selected independent variables was determined using regression analysis.

RESULTS

One hundred eighteen Black and Hispanic patients were included for analysis, with average age 49.59 ± 9.51 years and body mass index 30.11 ± 5.00 kg/m2. In the multivariate model for predicting satisfaction with outcome, only satisfaction with preoperative information (P < 0.001) was a statistically significant predictor during early and late postoperative evaluations. For predicting satisfaction with surgeon, satisfaction with information (P < 0.001) remained a significant predictor in the early and late postoperative evaluations, with lower body mass index as an additionally significant predictor during the late postoperative period.

CONCLUSIONS

Patient satisfaction with preoperative information received is the single most significant factor associated with Black and Hispanic patient satisfaction with outcome and plastic surgeon. This finding encourages further research on effective and culturally inclusive information delivery so as to both improve patient satisfaction and reduce healthcare disparities.

Analysis of Breast Aesthetic Revision Procedures after Unilateral Abdominal-based Free-flap Breast Reconstruction: A Single-center Experience with 1251 Patients

Although autologous free-flap breast reconstruction is the most durable means of reconstruction, it is unclear how many additional operations are needed to optimize the aesthetic outcome of the reconstructed breast. The present study aimed to determine the average number of elective breast revision procedures performed for aesthetic reasons in patients undergoing unilateral autologous breast reconstruction and to analyze variables associated with undergoing additional procedures.

Methods

A retrospective review of all unilateral abdominal-based free-flap breast reconstructions performed from 2000 to 2014 was undertaken at a tertiary academic center.

Results

Overall, 1251 patients were included in the analysis. The average number of breast revision procedures was 1.1 ± 0.9, and 903 patients (72.2%) underwent at least one revision procedure. Multiple logistic regression analysis demonstrated that younger age, higher body mass index, and prior oncologic surgery on the reconstructed breast were factors associated with increased likelihood of undergoing a revision procedure. The probability of undergoing at least one revision increased by 4% with every 1-unit (kg/m²) increase in a patient's body mass index. Multiple Poisson regression modeling demonstrated that younger age, prior oncologic surgery on the reconstructed breast, and bipedicle flap reconstruction were significant factors associated with undergoing a greater number of revision procedures.

Conclusions

Most patients who undergo unilateral autologous breast reconstruction require at least one additional operation to optimize their breast aesthetic results. Young age and obesity increase the likelihood of undergoing additional operations. These findings can aid reconstructive microsurgeons in counseling patients and establishing patient expectations prior to their undergoing microvascular breast reconstruction.

Risk Stratification of Surgical Site Outcomes by BMI & Flap Type in Autologous Breast Reconstruction

INTRODUCTION

Afflicting 2 million lives annually worldwide, breast cancer remains devastating. This study utilized a continuously updated network of electronic medical records (TriNetX Inc, Cambridge, MA) for analysis of 90-day postoperative outcomes of autologous breast reconstruction by increasing body mass index (BMI).

METHODS

The deidentified electronic medical records (EMRs) of 29,453,000 females, age 18-99 years, were retrospectively screened from 45 healthcare organizations. A combined cohort of 7136 patients undergoing autologous breast reconstruction via transverse rectus abdominus muscle (TRAM), deep inferior epigastric perforator (DIEP), or latissimus flap was categorized by BMI into 5 subgroups: normal (n = 3568), overweight (n = 1239), class I (n = 1166), class II (n = 807), and class III (n = 356) obesity. The normal BMI cohort was then compared with each elevated BMI cohort. BMI strata were analyzed for risk of surgical-site occurrences within 90 days of surgery using CPT codes. Stringent propensity score matching was performed.

RESULTS

For the combined group (N = 7136), significant linear increases in risk were observed with increasing BMI for infection (risk ratio [RR] 1.39-2.91,p < 0.05) and dehiscence (RR 2.65-5.17, p < 0.05). Similar linear increases were observed for the abdominally based group (N = 5454) for infection (RR 1.45-2.47, p < 0.05) and dehiscence (RR 2.54-4.77, p < 0.05). For DIEP (N = 4874), near-linear increases were observed for infection (RR 1.60-2.79, p < 0.05) and dehiscence (RR 1.57-5.59, p < 0.05). For TRAM (N = 714), significant increases were observed for seroma, infection, dehiscence, deep vein thrombosis (DVT), sepsis, and PE while increased risks of seroma, DVT, PE, and hernia were observed for latissimus (N = 1380).

CONCLUSIONS

Regardless of flap type, our analysis suggests that a BMI> 39.9 is the inflection point beyond which it may be beneficial not to perform autologous breast reconstruction. Limitations include this study's retrospective nature; thus, future prospective studies would be beneficial.

Comparison of surgical and patient-reported outcomes between 85 profunda artery perforator flaps and 122 deep inferior epigastric perforator flaps as first choice treatment for breast reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap for breast reconstruction was first published in 2012. Since then, many centers implemented its application as second-line treatment for breast reconstruction in cases where patient characteristics make the deep inferior epigastric perforator (DIEP) flap not feasible to perform. In our center, we established the PAP flap as a first-line procedure for a multitude of reasons for a specific patient population. This study describes perioperative measure, clinical outcomes, and patient-reported outcome measures in comparison to the gold standard, the DIEP flap.

METHODS

In this study, we analyzed all PAP flaps and DIEP flaps performed in a single center between March 2018 and December 2020. We present patient characteristics, surgical technique, perioperative care, surgical outcomes, and complications. The Breast-Q was used to assess patient-reported outcome measures.

RESULTS

A total of 85 PAP flaps and 122 DIEP flaps were performed within 34 months. Average follow-up was 11.6 ± 5.8 months for the PAP group and 11.1 ± 5.8 months for the DIEP group (p = 0.621). Patients' average body mass index was higher in the DIEP flap recipients. Operation time was shorter and ambulation faster in PAP flap recipients. DIEP flap application resulted in higher Breast-Q scores.

CONCLUSIONS

While the PAP flap demonstrated favorable perioperative measures, outcome measures were better with the DIEP flap. The PAP flap is fairly new and demonstrates high potential while still showing a need for refinement compared to the DIEP flap.

Body mass index and benign breast surgeries: a survey of plastic surgeons’ knowledge and attitudes

Background

The academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients.

Methods

An online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022.

Results

There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher.

Conclusions

Respondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences.

Trends and Early Complications in Direct-to-Implant Breast Reconstruction: An Updated Analysis of the ACS-NSQIP Database

Background: Rates of direct-to-implant (DTI) breast reconstruction, in which breast implants are placed at the time of mastectomy, have been consistently rising. Advances in surgical adjuncts and technology, such as acellular dermal matrices (ADM), have made DTI reconstruction safer and more reliable. However, few studies have characterized early (30-day) postoperative complications following DTI. The aim of this study was to obtain a current understanding of early postoperative outcomes following DTI breast reconstruction. Methods: Using data from the American College of Surgeons-National Surgical Quality Improvement Program, we analyzed complications for female patients who underwent DTI reconstruction from 2017 to 2019, as well as trends in DTI reconstruction from data on mastectomy and DTI reconstruction from 2010 to 2019. We grouped complications into major surgical (including return to the operating room) or medical complications. Statistical analysis was performed using Fischer's exact test for categorical variables, Student's t-test for continuous variables, and logistic regression. Results: DTI breast reconstruction rates have increased since 2010. Among our 2017-2019 cohort of 4204 patients, the early major surgical complication rate was approximately 10% (422 patients) and the major medical complication rate was 0.83% (35 patients). Regression modeling identified body mass index, smoking status, hypertension, bleeding disorders, and intraoperative blood transfusion as having a relationship with surgical complications ( P < .001). Conclusions: Despite increased use of ADM and indocyanine green angiography, compared to prior studies, early postoperative complications have remained stable. Further studies are needed to assess long-term complications and patient-reported outcomes in DTI breast reconstruction.

Comparison of Patients Satisfaction with Direct to Implant versus Latissimus Dorsi Flap with Implant Breast Reconstruction Using Breast-Q

Background  The latissimus musculocutaneous flap (LD flap) is a useful option for breast reconstruction following mastectomy. It has the advantage of obtaining sufficient tissue padding and natural shape by using autologous tissue. However, with the emergence of the skin-sparing mastectomy technique and artificial dermis matrix, direct-to-implant (DTI) breast reconstruction has become the first choice of surgery. The purpose of this study was to compare the satisfaction levels of patients who underwent DTI and LD flap with implant using patient-reported Breast-Q results.

Methods  A retrospective study was performed reviewing the records of 49 women who underwent immediate breast reconstruction with DTI or LD flap with implant and responded to the BREAST-Q questionnaire after the operation. The patient-reported breast-Q results were analyzed and correlated to the demographic information and intraoperative information.

Results  A total of 26 patients who underwent reconstruction with LD flap with implant and 23 patients with DTI were identified and responded to the questionnaire after an average of 32.3 and 10.4 months postoperation, respectively. According to the patient response to the breast-q values, satisfaction with breast was 60.0 and 57.0 points, psychosocial well-being 61.0 and 60.0 points, and sexual well-being 41.0 and 43.0 points in the two groups. Overall, there was no significant difference in the breast-Q score between the two groups.

Conclusion  Patients who underwent DTI breast reconstruction seemed equally satisfied with the appearance and outcome of their breast reconstruction compared with LD flap with implant. Therefore, it appears that DTI is adequately replacing LD with implant.

Single Institution Evolution in Defining an Algorithm for Prevention and Management of Severe Complications in Direct-to-Implant Breast Reconstruction

BACKGROUND

Complications including infection and wound dehiscence are major concerns for direct-to-implant (DTI) breast reconstruction. However, the risk factors associated with severe complications and implant salvage remain unclear.

METHODS

Retrospective study of all patients undergoing unilateral DTI breast reconstruction from 2014 through 2019. The risk factors associated with complications and prosthesis explantation were identified using multivariate logistic regression modeling and interaction analyses.

RESULTS

Among 1027 patients enrolled, 90 experienced severe complications, 41of which underwent prosthesis explantation, while 49 were successfully salvaged. Multivariate analysis demonstrated that patients with larger implant size (p=0.003), use of bovine mesh (p<0.001), adjuvant radiotherapy (p=0.047), low plasma albumin (p=0.013), and elevated blood glucose (p=0.006) were significantly more likely to suffer complications. Adjuvant radiation (OR: 7.44; 95%CI, 1.49-37.18; p = 0.014) and obesity (OR, 4.17; 95%CI, 1.17-14.88; p = 0.028) had significantly lower rates of implant salvage as well as surgical site infection (SSI) and wound dehiscence, while mastectomy skin flap necrosis was not associated with device explanation. There were no differences in complication and explantation rates between nipple-sparing and skin-sparing mastectomies. However, the combined impact of SSI and wound dehiscence added over fourteen-fold higher risk of prosthesis explantation (95%CI, 9.97-19.53).

CONCLUSION

Success in direct-to-implant breast reconstruction is multifactorial. Larger implant size, adjuvant radiation therapy, diabetes, and malnutrition demonstrate increased risk of complications in the DTI approach. Surgical site infections and wound dehiscence should be treated aggressively, but the combination of both complications portends poor salvage rates.

Restoring Breast Volume in High BMI Patients: A Single-Center Review of Breast Reconstruction Using Hyperinflated Saline Implants

BACKGROUND

Breast reconstruction in the obese patient is often fraught with poor patient satisfaction due to inadequate volume restoration. The off-label hyperinflation of saline implants is a direct yet controversial solution to this problem, with limited studies in the literature. This study sought to determine the safety and efficacy of this technique for breast reconstruction.

METHODS

A retrospective chart review was performed to identify all patients with a body mass index (BMI) greater than or equal to 30 kg/m2 who underwent breast reconstruction between the years 2013 to 2020 with saline implants filled beyond the manufacturer's maximum recommended volume.

RESULTS

The 21 patients identified had an average age of 49 years. The mean BMI was 39.5 kg/m2. A total of 42 implants were placed; 34 were 800 mL, 4 were 750 mL, and 4 were 700 mL. The average overfill volume was 302 mL (138%). Mean follow-up was 65.0 months. Of these, 1 (4.8%) patient with a history of chest wall radiotherapy underwent reoperation for unilateral implant exposure 27 days after the index procedure, no patient sustained spontaneous leak or rupture, and 1 patient had unilateral deflation following emergent central line and pacemaker placement 2 years after the implant was placed for an unrelated cardiovascular event.

CONCLUSIONS

Hyperinflation of saline implants beyond the maximum recommended volume may be considered for volume replacement in obese patients undergoing implant-based breast reconstruction. This practice is well tolerated, has a complication rate comparable to using implants filled to the recommended volume, and has the potential to restore lost breast volume in the obese patient post mastectomy.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

Prepectoral Breast Reconstruction in Morbidly Obese Patients

Prosthetic breast reconstruction via the subpectoral approach in morbidly obese patients (body mass index: ≥40 kg/m²) has been reported to be associated with an increased risk of perioperative complications and poor outcomes. Further, immediate reconstruction appears to carry a higher risk of poor outcomes than delayed reconstruction in this population. The impact of morbid obesity on outcomes after prepectoral breast reconstruction has not yet been evaluated, and such was the purpose of this study.

Autologous Versus Alloplastic Reconstruction for Patients with Obesity: A Systematic Review and Meta-analysis

BACKGROUND

Autologous flaps may have superior outcomes when compared to implant breast reconstruction in patients with obesity. To date, no published review has illustrated the superiority of autologous to implant-based reconstruction in this study group in terms of aesthetics outcomes and surgical complications.

METHODS

A systematic search was conducted on PubMed, Cochrane, Google Scholar, and Embase from inception to December 31, 2020. Studies comparing the outcomes (patient satisfaction and complications) of autologous versus implant-based reconstruction in patients with BMI > 30 were selected.

RESULTS

The search yielded 1633 articles, of which 76 were assessed in full text. A total of 12 articles fit inclusion for qualitative review; of them, 7 were meta-analyzed. Autologous reconstruction had a lower incidence of infection (OR 0.74 [95% CI 0.59, 0.92]), hematoma/seroma formation (OR 0.34 [95% CI 0.23, 0.49]), and reconstructive failure (OR 0.47 [95% CI 0.36, 0.62]), but not skin necrosis (OR 0.95 [95% CI 0.73, 1.25]) or wound dehiscence (OR 1.03 [95% CI 0.72, 1.49]) when compared to implant-based reconstruction. Deep vein thrombosis (DVT) and pulmonary embolism occurred more frequently with autologous versus alloplastic reconstruction (OR 2.21 [95% CI 1.09, 4.49] for DVT and OR 2.49 [95% CI 1.13, 5.48] for PE). BREASTQ scores were higher for the autologous breast reconstruction when compared to implant-based group, but failed to reach significance (p value >0.05).

CONCLUSION

The current evidence in the literature suggests that autologous breast reconstruction has lower surgical complication rate when compared to implant-based reconstruction at the expense of higher risk of thrombotic complications for patients with BMI > 30.

LEVEL OF EVIDENCE III

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 .

Salvage of infected implant-based breast reconstructions in morbidly obese patients with explantation and replacement with an autologous muscle-sparing latissimus dorsi flap

Morbidly obese patients who undergo reconstruction with implants after mastectomy are at higher risk of reconstructive failure. Prosthetic infection historically required explantation with plans for delayed implant-based reconstruction or conversion to autologous tissue. Loss of the skin envelope in the delayed setting often leads to poor aesthetic outcomes. Recently, several different approaches for salvage of infected implant-based reconstructions with immediate prosthetic replacement have been described. While these strategies have proven useful in many patients, we find a prohibitive risk of failure of this approach in the morbidly obese, especially in those undergoing chemotherapy or who have been radiated. Instead, we have offered these patients salvage of their reconstructions with explantation and immediate autologous conversion to a muscle-sparing latissimus dorsi flap. Here, we report on 11 morbidly obese patients where this strategy was utilized.

Immediate Breast Reconstruction Using the Goldilocks Procedure: A Balance between More Surgery and Patient Satisfaction

BACKGROUND

Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction.

METHODS

A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors.

RESULTS

Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not.

CONCLUSIONS

Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

BMI Specific Complications Following Implant-Based Breast Reconstruction after Mastectomy

Background: Breast reconstruction has a positive impact on body image and quality of life for women after experiencing the physically and psychologically demanding process of mastectomy. Previous studies have presented body mass index (BMI) as a predictor for postoperative complications after breast reconstruction, however, study results vary. This retrospective study aimed to investigate the impact of patients’ BMI on postoperative complications following implant-based breast reconstruction. Methods: All implant-based breast reconstructions performed at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Vienna from January 2001 to March 2018 were evaluated. A total of 196 reconstructed breasts among 134 patients met eligibility criteria. Demographic data, surgical techniques, as well as major and minor complications within a one-year follow-up period were analyzed. Results: Patients’ BMI did not show a significant impact on complication rates. The overall incidence of postoperative complications was 30.5% (40/131) of which 17.6% required reoperation. Impaired wound healing (18.3%), seroma (6.1%), hematoma (4.6%), capsular contraction (4.6%) and infection (3.8%) were the most common complications. Conclusion: In our study cohort, BMI was not associated with a significantly higher risk of complications. However, postoperative complications significantly increased with a longer operative time and resulted in an extended length of hospital stay.

Giving meaning to patient reported outcomes in breast reconstruction after mastectomy - A systematic review of available scores and suggestions for further research

Background

There are three patient reported outcome measure instruments (PROMs) that have adequate content validity for breast reconstruction, BREAST-Q, BRECON-31 and EORTC QLQ-BRECON-23, and they all have been robustly validated. The aim of this study was to systematically review scores giving meaning to validated PROMs for breast reconstruction after mastectomy and discuss methods to enable interpretation of them.

Methods

A systematic review was performed according to the recommendations of PRISMA. Prospero CRD42021255874. Included articles had to meet criteria defined in a SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type). The included studies were critically appraised using the GRADE approach.

Results

Three articles were finally included in the review: two studies on scores for healthy controls and one on minimally important differences (MIDs), both of BREAST-Q. All of the studies were performed in North America. Only MIDs based on statistical characteristics, and not on what constitutes a relevant change for the patient, exist. The risk of bias was evaluated as very high and moderate, respectively, of inconsistencies as low, of indirectness as high, of imprecisions as low, and of publication bias as probably low.

Conclusions

The overall certainty of evidence for scores giving meaning to PROMs for breast reconstruction is low (GRADE ƟƟОО). More studies are needed to establish relevant healthy control scores and what constitutes a relevant clinical difference for patient-reported outcome measures for breast reconstruction after mastectomy. Clinical implications of the findings and suggestions for further research are suggested in the article.

•

Patient reported outcome measurements have to be clinically interpretable to make sense.

•

Three articles on scores giving meaning to PROMs for breast reconstruction post-mastectomy exist.

•

More studies are needed to establish relevant controls and clinical differences in scores.

•

Clinical implications and suggestions for further research are discussed.

The Goldilocks Procedure with and without Implant-Based Immediate Breast Reconstruction in Obese Patients: The Mayo Clinic Experience

BACKGROUND

Obesity is a risk factor for complications in breast reconstruction. Thus, implant-based immediate breast reconstruction in obese women may be controversial. The authors analyzed obese patients who underwent skin-sparing mastectomy using Wise-pattern incisions (Goldilocks procedure) and compared outcomes between two groups: Goldilocks with immediate breast reconstruction and Goldilocks only.

METHODS

A retrospective review was performed of patients with a body mass index of 30 kg/m2 or higher who underwent the Goldilocks procedure at the Mayo Clinic Health System from 2012 to 2019. Data were extracted from electronic medical records. Minor complications (partial-thickness wound dehiscence or flap necrosis, or tissue expander/implant malposition) and major complications (full-thickness wound dehiscence or flap necrosis, capsular contracture, tissue expander/implant explantation, or unplanned reoperation or readmission) were compared between groups. Patient-reported outcomes using BREAST-Q questionnaires were also assessed.

RESULTS

One hundred five patients (181 breasts) were included. Mean ± SEM age and body mass index were 57.1 ± 10.4 years and 37.9 ± 5.8 kg/m2 for the Goldilocks-only group and 51.5 ± 1.1 years and 35.5 ± 0.4 kg/m2 for the Goldilocks with immediate breast reconstruction group, respectively. Median follow-up time was 15.1 months (interquartile range, 10.0 to 28.6 months). Overall, 96 breasts underwent the Goldilocks-only procedure and 85 Goldilocks with immediate breast reconstruction. Multivariable analyses revealed a higher rate of minor complications (adjusted hazard ratio, 2.83; 95 percent CI, 1.22 to 7.02) and major complications (adjusted hazard ratio, 2.26; 95 percent CI, 1.25 to 4.24) in the Goldilocks with immediate breast reconstruction group compared with the Goldilocks-only group, at any given time. Patient satisfaction was not statistically different between groups.

CONCLUSIONS

The Goldilocks procedure is a feasible breast reconstructive option in obese patients; however, when it is performed with immediate breast reconstruction, it is associated with higher rates of complications. For patients with a body mass index of 40 kg/m2 or greater, the authors recommend the Goldilocks-only procedure or delayed reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction?

BACKGROUND

Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up.

METHODS

Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed.

RESULTS

Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts.

CONCLUSIONS

Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.

Is there any difference in perioperative characteristics or postoperative complications between overweight, normal-weight and obese patients in delayed DIEP reconstructions?

Increased number of overweight and obese women are seeking breast reconstruction. Studies have demonstrated that obese experience increased rates of complications, but less data is available considering overweight patients. We analyzed the impact of body mass index (BMI) on perioperative characteristics and complications in unilateral delayed deep inferior epigastric perforator flap (DIEP) reconstructions. The records of patients with DIEP reconstruction performed between 2014 and 2020, were retrospectively analyzed. Patients were categorized into obese (BMI ≥30), overweight (BMI 25.0-29.9), and normal-weight groups (BMI <25). Patient characteristics (age, comorbidity, radiation, abdominal surgery, ASA category, and smoking), perioperative characteristics (length of operation, blood loss, vasoactive drugs, fluid administration, and urine output), and postoperative complications were recorded. The study included 308 patients. Of these, 104 (34%) were normal-weighted, 142 (46%) overweight and 62 (20%) obese. Among patients with BMI ≥ 25, blood loss increased (p = 0.002) and the length of operation tended to be longer (p = 0.072). No between-groups difference existed in fluid administration (p = 0.319), urine output (p = 0.425), or use of vasoactive drugs (p = 0.815). There was no statistically significant difference in overall complications (p = 0.122) between BMI groups. Blood loss >150ml was associated with both minor and major complications (p = 0.022). Greater BMI moderated with the radiation therapy for higher risk of minor complications (OR 42.0, 95%CI 3.54-49.7, p = 0.003). We conclude that greater BMI alone is not associated with a higher overall complication rate, but both overweight and obesity may be moderators for other risk factors.

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

BACKGROUND

 From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

 A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications.

RESULTS

 When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications.

CONCLUSION

 DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

Breast Reconstruction Completion in the Obese: Does Reconstruction Technique Make a Difference in Its Achievement?

BACKGROUND

 Breast mound and nipple creation are the goals of the reconstructive process. Unlike in normal body mass index (BMI) women, breast reconstruction in the obese is associated with increased risk of perioperative complications. Our aim was to determine if reconstruction technique and the incidence of perioperative complications affect the achievement of reconstruction completion in the obese female.

METHODS

 Consecutive obese women (BMI ≥30) who underwent mastectomy and implant or autologous reconstruction were evaluated for the completion of breast reconstruction.

RESULTS

 Two hundred twenty-five women with 352 reconstructions were included. Seventy-four women underwent 111 autologous reconstructions and 151 women underwent 241 implant-based reconstructions. Chemotherapy, radiation, and delayed reconstruction timing was more common in the autologous patients. Major perioperative complications (requiring hospital readmission or unplanned surgery) occurred more frequently in the implant group (p ≤ 0.0001). Breast mounds were completed in >98% of autologous cases compared with 76% of implant cases (p ≤ 0.001). Nipple areolar complex (NAC) creation was completed in 57% of autologous patients and 33% of implant patients (p = 0.0009). The rate of successfully completing the breast mound and the NAC was higher in the autologous patient group (Mound odds ratio or OR 3.32, 95% confidence interval or CI 1.36-5.28 and NAC OR 2.7, 95% CI 1.50-4.69).

CONCLUSION

 Occurrence of a major complication in the implant group decreased the rate of reconstruction completion. Obese women who undergo autologous breast reconstruction are more likely to achieve breast reconstruction completion when compared with obese women who undergo implant-based breast reconstruction.

Mastectomy with immediate breast reconstruction: Results of a mono-centric 4-years cohort

Introduction

Oncological safety, quality of life and cosmetic outcomes seems to be similar between breast conserving surgery (BCS) and mastectomy with immediate breast reconstruction (IBR). We report our experience of IBR for consecutive mastectomies realized in a recent period of four years in order to determined immediate surgical results according to type of mastectomy and type of reconstruction, as mains objectives.

Methods

All mastectomies with IBR during years 2016–2019 were included. A retrospective analysis with prospective data collection was performed.

Results

We analyzed 748 IBR: 353 nipple-sparing mastectomies (NSM), 391 skin-sparing mastectomies (SSM) and 4 standard mastectomies, 551 with definitive implant or expanders and 196 with latissimus dorsi-flap (LDF). More NSM were performed during the 2 last years and more LDF were performed for high BMI, high breast cup-size, neo-adjuvant chemotherapy and radiotherapy and local recurrence. We realized 111 robotic NSM and 125 robotic LDF. Longer duration of surgery was significantly associated with the robotic procedures.

The overall complications crude rate was 31.4% with 9.9% of re-operations and 5.8% of implant loss. Grade 2–3 complications were significantly associated with smoking. Breast complications occurred in 32.9% of mastectomies with principally skin or nipple-areola-complex suffering or necrosis, hematomas and infections. A predictive score was determined to evaluate risk of complications before surgery.

Conclusion

Mastectomy with IBR seems to be a safe technique with an acceptable complication rate which is increased by tobacco use, high breast cup-size and IBR-type.

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Mastectomy with immediate breast to determined immediate surgical results.

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More Nipple Sparing Mastectomy performed during the 2 last years.

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More Latissimus dorsi-flap performed for high BMI, high breast cup-size, after radiotherapy.

Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients

BACKGROUND

Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m²] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap.

METHODS

A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated.

RESULTS

Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m², including 12 patients with BMI > 50 kg/m². Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively.

CONCLUSIONS

These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.

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.