A Paradigm Shift in U.S. Breast Reconstruction: Part 2. The Influence of Changing Mastectomy Patterns on Reconstructive Rate and Method

Simple prosthesis versus prosthesis plus titanium-coated polypropylene mesh for implant-based immediate breast reconstruction after total mastectomy for breast cancer

Background

Our study compares the cosmetic effects, postoperative complications, and quality of life of immediate breast reconstruction with simple prosthesis or prosthesis plus titanium-coated polypropylene mesh (TCPM) after total mastectomy for breast cancer.

Methods

In total, 69 patients who underwent total mastectomy, sentinel lymph node biopsy, and immediate prosthetic breast reconstruction from January 2015 to December 2018 in our hospital were selected, and their cosmetic effects, complications, and quality of life after reconstruction were recorded immediately after surgery and 6 months after surgery.

Results

Of these 69 patients, 29 were in the simple prosthesis group and 40 in the prosthesis + TCPM group. The incidence of surgical complications was 17.2% in the simple prosthesis group (5/29; including 4 cases of capsular contracture and 1 case of infection) 15.0% in the prosthesis + TCPM group (6/40; 1 case of flap necrosis, 2 cases of poor wound healing, 2 cases of hematomas, and 1 case of inadequate blood supply to nipple). The complications were successfully managed after symptomatic treatment in both groups. No prosthesis loss was noted. The incidence of postoperative complications showed there to be no significant differences between these two groups (P=0.06, χ²=0.80). The satisfaction rate of patients on cosmetic effects was 95.0% (38/40) in the prosthesis + TCPM group, significantly higher than that in the simple prosthesis group (75.90%, 22/29) (P=0.05, χ²=3.87). The quality of life in the simple prosthesis group at 2 weeks and six months after the operation was significantly lower than that in the prosthesis + TCPM group. The incidence rate of arm pain and fatigue at 2 weeks after operation was significantly higher than that in the prosthesis + TCPM group (P=0.04, χ²=4.42). The satisfaction of family life and sexual interest 6 months after the operation was also significantly lower in the simple prosthesis group than in the prosthesis + TCPM group (P=0.03, χ²=4.95).

Conclusions

Breast reconstruction with prosthesis combined with TCPM does not increase surgical complications and has a good cosmetic effect and high patient satisfaction. Thus, it is a safe and reconstruction method.

Porcine Acellular Peritoneal Matrix in Immediate Breast Reconstruction: A Multicenter, Prospective, Single-Arm Trial

BACKGROUND

Use of biological implants such as acellular dermal matrices in tissue expander breast reconstruction is a common adjunct to submuscular implant placement. There is a paucity of published prospective studies involving acellular matrices. The authors sought to evaluate a porcine-derived acellular peritoneal matrix product for immediate breast reconstruction.

METHODS

A prospective, single-arm trial was designed to analyze safety and outcomes of immediate tissue expander-based breast reconstruction with a novel porcine-derived acellular peritoneal matrix surgical mesh implant. Twenty-five patients were enrolled in this industry-sponsored trial. Patient demographics, surgical information, complications, histologic characteristics, and satisfaction (assessed by means of the BREAST-Q questionnaire) were evaluated.

RESULTS

Twenty-five patients (44 breasts) underwent mastectomy with immediate breast reconstruction using tissue expanders with acellular peritoneal matrix. Sixteen reconstructed breasts experienced at least one complication (36 percent). Seroma and hematoma occurred in one of 44 (2.3 percent) and two of 44 breasts (4.6 percent), respectively. Wound dehiscence occurred in four of 44 breasts (9.1 percent). Three subjects experienced reconstruction failure resulting in expander and/or acellular peritoneal matrix removal (6.8 percent); all failures were preceded by wound dehiscence. Histologic analysis showed cellular infiltration and product resorption. Results of the BREAST-Q demonstrated a level of postoperative patient satisfaction consistent with results in the available literature.

CONCLUSIONS

Prepared porcine-derived acellular peritoneal matrix is a safe adjunct in immediate two-stage tissue expander-based breast reconstruction. Further studies are required to determine efficacy compared to current commercially available acellular matrices.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Dermal Autograft Using Donor Breast as Alternative to Acellular Dermal Matrices in Tissue Expander Breast Reconstruction: A Comparative Review

BACKGROUND

Shifting preference for implant-based breast reconstruction has resulted in an increased use of acellular dermal matrix (ADM) in tissue-expander breast reconstruction. The benefits afforded by ADM must be weighed against a potential increased risk for postoperative complications. Dermal autograft-assisted breast reconstruction using autograft harvest from the lower abdomen has been shown to result in equivalent aesthetics and patient satisfaction compared with ADM at a lower cost, with fewer complications. The purpose of this study was to review a series of patients who underwent bilateral mastectomy and immediate dermal autograft-assisted tissue expander (TE) breast reconstruction using the non-cancerous breast as a donor site, comparing the outcomes with a concurrent cohort of patients undergoing ADM-assisted reconstruction to determine the relative safety, cost, and effectiveness of the 2 procedures.

METHODS

The study population included all patients who underwent dermal autograft-assisted TE breast reconstruction, using the contralateral cancer-free breast as the source of dermal autograft, between 2010 and 2015. The ADM cohort consisted of patients who underwent bilateral mastectomy and immediate ADM-assisted TE breast reconstruction during the same period. Univariate analysis was performed for demographic data, complications, operative cost, and operative time. Data were compared using the Wilcoxon rank sum test for nonparametric data and χ analyses for continuous and categorical variables. Significance was defined as P value less than 0.05.

RESULTS

Seventeen patients received dermal autograft using the non-cancerous breast donor site. Twenty-seven patients who underwent ADM-assisted reconstruction during the same period were identified. Significantly higher cost was demonstrated between groups (ADM, US $9999.87; autograft, US $3924.19; P < 0.0001). No significance difference existed operative time (autograft, 97 min; ADM, 120 min). No difference was found in wound healing complications (ADM, 14.8%; autograft, 23.53%; P = 0.47). No significant difference was found in major complications (ADM, 26%; autograft, 17.65%; P = 0.52) or infectious complications (ADM, 26%; autograft, 17.65%; P = 0.52).

CONCLUSIONS

Dermal autograft-assisted breast reconstruction using the contralateral non-cancerous breast as the source of dermal autograft harvest represents a lower cost alternative to ADM without increased risk of postoperative complications.