Surgical Outcomes of Implant versus Autologous Breast Reconstruction in Patients with Previous Breast-Conserving Surgery and Radiotherapy

National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches

BACKGROUND

Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates.

METHOD

Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p < 0.05.

RESULTS

Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p < 0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06 ± 0.32) and two-stage IBR (0.05 ± 0.32, p = 0.95). Immediate IBR demonstrated 12% (OR = 0.88, p = 0.0022) and 70% (OR = 0.30, p < 0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66 % lower odds of requiring only fat grafting than ABR (OR = 0.34, p < 0.001).

CONCLUSION

ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.

Meta-Analysis of Immediate Implant-Based Breast Reconstruction Versus Autologous Breast Reconstruction in the Setting of PMRT

BACKGROUND

It is still a controversial debate that which type of immediate breast reconstruction should be operated on breast cancer patients in the setting of postmastectomy radiotherapy. This meta-analysis compared incidence of complications requiring reoperation (CRR), reconstruction failure (RF) and patient-reported outcome between immediate autologous breast reconstruction (ABR) and immediate implant-based breast reconstruction (IBBR), tissue expander/implant reconstruction mostly, in the setting of postmastectomy radiotherapy.

METHODS

Systematic and thorough research was conducted to search for studies published before August 1, 2022, by using three online databases. Studies that covered complications or reconstruction failure between two cohorts were included. To evaluate the possible bias in the included studies, the Newcastle-Ottawa Scale was applied.

RESULTS

Eight studies presenting 1261 patients were enrolled. The relative risk associated with reconstructive failure favored IBBR (RR = 8.61; 95% CI, 2.84-26.08; P = 0.0001). While the risk for complications requiring reoperation was not significantly different between two groups, either include reconstruction failure (RR = 1.45 95% CI, 0.82-2.55; P = 0.20) or not (RR = 0.63 95% CI, 0.28-1.43; P = 0.27). However, because statistical definitions and methodologies vary, the synthesized result should be taken critically.

CONCLUSION

Patients with IBBR have more possibility experiencing RF compared that with ABR, while the chance for CRR is not that different between two groups. For the purpose of clinical practice refinement, more high-quality studies are needed.

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 .

The FALD-V: A predictive formula for preoperative volume assessment of adipose tissue transplantation in FALD flap

BACKGROUND

The fat-augmented latissimus dorsi (FALD) flap is an evolution of the traditional latissimus dorsi (LD) flap, which allows to obtain a total autologous breast reconstruction (BR) avoiding the use of breast implants. The aim of this study was to develop a predictive preoperative formula in order to estimate and optimize the amount of fat to be transferred during FALD flap BR, using only anthropometric measurements.

METHODS

We conducted a prospective clinical study between September 2020 and April 2023. All patients underwent back pre-operative ultrasound scan to assess the subcutaneous skin paddle thickness (SPT) and a regression analysis was performed to evaluate which anthropometric variable had a better correlation with this thickness.

RESULTS

Data from 66 FALD flaps were collected. The mean SPT was 11.95 mm (SD 4.56). A significant correlation between SPT and body mass index (BMI) was found (r = 0.640, p < 0.0001). Using the fat-to-capacity ratio (113%), the following formula (the FALD-V) was developed to predict the needed fat transfer into FALD flap: [-509 + 12.32 × BMI + 11.71 × skin paddle width + 17.43 × skin paddle height] × 1.13. The considered variables (BMI, skin paddle width and skin paddle height) were statistically significant (p < 0.001, p = 0.0483, p = 0.0154, respectively). The cross-validation confirmed the accuracy of the formula (r = 0.810).

CONCLUSION

The FALD-V can be used as an innovative complimentary device in the planning of FALD flap one-stage total autologous BR. To enhance its application, a 3.0 WebApp at www.braflap.com (and www.breast-v.com) is available free of charge for both iOS and Android devices.

LEVEL OF EVIDENCE

II.

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.