Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70:103-110. [PMID: 21862916 DOI: 10.1097/sap.0b013e31822ed5ce]

Risk of Bleeding Versus Venous Thromboembolism After Surgery for Breast Cancer: A National Surgical Quality Improvement Program Analysis

INTRODUCTION

Patients who undergo surgery for breast cancer are at risk for venous thromboembolism (VTE) and bleeding, which can lead to significant consequences on outcomes. This study examined factors related to VTE and bleeding risk in breast cancer surgery, with and without reconstruction. We also investigated the relationship between operative time and resident involvement on bleeding and VTE risk.

METHODS

Using the ACS-NSQIP database, patients who underwent mastectomy, implant, pedicled, or free flap reconstruction from 2005 to 2021 were identified. Resident involvement was available from 2007 to 2010. We fitted two logistic regressions to model the log odds of bleeding occurrence and VTE as linear functions of procedure type, controlling for age, body mass index, and comorbidities.

RESULTS

Implant reconstruction had significantly reduced 30-d incidence of bleeding, compared to those who underwent transverse rectus abdominus muscle flap (P < 0.001). Free flap was associated with a significant increase in bleeding but not VTE risk (P < 0.001; P = 0.132). Increase in operative time significantly increased the risk of bleeding and VTE (P < 0.001). For surgeries with resident involvement coded, there was no significantly increased risk of bleeding or VTE (P = 0.600; P = 0.766).

CONCLUSIONS

Implant reconstruction remains the procedure with the lowest risk of both bleeding and VTE. Free flap reconstruction did not show a significantly increased risk of VTE, potentially expanding reconstruction options for patients previously excluded from autologous reconstruction. Surgeons should be mindful of operative time, with re-evaluation of risk factors with each additional hour of surgery, irrespective of reconstruction type. Resident involvement in surgeries should continue to be encouraged by faculty.

Alpha Defensin-1 Level Correlates with Periprosthetic Infection Severity following Implant-based Breast Reconstruction

Background

Accurate diagnosis of periprosthetic infections following breast reconstructions is paramount to reduce morbidity. Alpha defensin-1 (AD-1) is an antimicrobial peptide released by neutrophils. This study evaluates the relationship between quantitative AD-1 levels and infection severity in patients with suspected periprosthetic infection.

Methods

Retrospective review was conducted of patients with prior breast implant reconstruction undergoing surgery for either suspected infection or prosthesis exchange and revision. The AD-1 level in periprosthetic fluid was sent for quantitative analysis. Association between AD-1 levels with outcomes, management, systemic markers of infection, and overall infection severity was evaluated.

Results

Thirty-eight breasts were included. Infected breasts had higher AD-1 levels (3.91 versus 0.14, P < 0.01), greater odds of erythema [odds ratio (OR) 2.98 (1.53-5.82), P = 0.01], purulence [OR 2.84 (1.51-5.35), P = 0.01], fever [OR 1.84 (1.15-2.93), P = 0.01], threatened implant exposure [OR 2.97 (1.48-5.95), P < 0.01], and true implant exposure [OR 1.79 (1.04-3.08), P = 0.04]. Increasing AD-1 was an independent risk factor for washout (P < 0.01), and explant [OR 2.48 (1.47-4.2), P < 0.01]. AD-1 positively correlated with white blood cell count (β = 1.81 cells/µL, P < 0.01), and serum lactate (β = 0.19 meq/L, P < 0.04). Increasing AD-1 level was an independent predictor of infection severity (χ² = 22.77, P < 0.01).

Conclusions

AD-1 levels correlate with infection severity, highlighting its potential both when clinical examination is ambiguous and when treatment response is being monitored. Although further evaluation is warranted, AD-1 may demonstrate utility in novel breast implant salvage algorithms.

Correlating state-specific and national trends in breast reconstruction after Medicaid expansion: A decade-long update on the Affordable Care Act's impact

While disparities in access to reconstruction persist, a comprehensive analysis comparing state-based outcomes and national patterns in breast reconstruction as a result of Medicaid expansion has never been examined. In this study, we investigated how breast reconstruction rates changed as a result of Medicaid expansion and compared these state-based findings to national counterparts. Patient data from the Healthcare Cost and Utilization Project among states that chose to expand Medicaid were compared with those from states that did not expand. The difference-in-differences estimate of expansion to nonexpansion states was 7.05 (p = 0.10) for implant-based reconstruction, -11.56 (p = 0.01) for autologous reconstruction, and -7.08 (p = 0.18) for overall reconstruction. Comparing rates of nonexpansion states to national trends yielded estimates of -0.06 (p = 0.04), 0.06 (p = 0.01), and 0.004 (p = 0.90) for implant-based, autologous, and overall breast reconstruction, respectively. Similarly, comparing rates of expansion states to national trends yielded estimates of 0.02 (p = 0.38), -0.05 (p = 0.03), and -0.02 (p = 0.44) for implant-based, autologous, and overall breast reconstruction, respectively. In this study on national health policy, Medicaid expansion was associated with a significant increase in autologous rates while state-specific trends alone did not appear to predict the national outcomes of sweeping legislative changes that were differentially applied among states.

[Update and Trends in Breast Reconstruction After Mastectomy]

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

Modern Approaches to Alternative Flap-Based Breast Reconstruction: Profunda Artery Perforator Flap

Autologous free flap breast reconstruction allows for natural-appearing breasts, while avoiding the risks associated with implants, including exposure, rupture, and capsular contracture. However, this is offset by a much higher technical challenge. The abdomen remains the most common tissue source for autologous breast reconstruction. However, in patients with scant abdominal tissue, prior abdominal surgery, or a desire to avoid scarring in this region, thigh-based flaps remain a viable alternative. The profunda artery perforator (PAP) flap has emerged as a preferred alternative tissue source, due to excellent esthetic outcomes and low donor-site morbidity.

Postoperative Complications Following Prepectoral Versus Partial Subpectoral Implant-Based Breast Reconstruction Using ADM: A Systematic Review and Meta-analysis

BACKGROUND

There is a paucity of evidence comparing the safety of prepectoral and partial subpectoral implant-based breast reconstruction using acellular dermal matrices (ADM). We performed a meta-analysis to evaluate the postoperative complications of the two approaches.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The rates of the complications were, respectively, pooled, and relative risk (RR) was estimated with 95% confidence intervals (CIs) to compare the incidence between the two cohorts.

RESULTS

Ten articles reporting on 2667 breast reconstructions were eligible. The hematoma rate was lower in the prepectoral group (RR  =  0.590, 95% CI 0.351-0.992). No significant difference was observed in terms of seroma (RR = 1.079, 95% CI 0.489-2.381), skin flap necrosis (RR = 0.936, 95% CI 0.587-1.493), infection (RR = 0.985, 95% CI 0.706-1.375), tissue expander/implant explantation (RR  =  0.741, 95% CI 0.506-1.085), wound dehiscence (RR = 1.272, 95% CI 0.605-2.673), capsular contracture (RR = 0.939, 95% CI 0.678-1.300) and rippling (RR = 2.485, 95% CI 0.986-6.261). The RR of animation deformity for the prepectoral group compared with the subpectoral group was 0.040 (95% CI, 0.002-0.853).

CONCLUSIONS

This systematic review suggested that with appropriate patient selection, prepectoral breast reconstruction could avoid animation deformity without incurring higher risk of early wound complications, capsular contracture or rippling than partial subpectoral breast reconstruction. Plastic surgeons should complete a comprehensive assessment of the patients before choosing appropriate surgical approaches in clinical practice.

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 .

A Paradigm Shift: Outcomes of Early Autologous Breast Reconstruction after Radiation Therapy

BACKGROUND

 Radiation creates significant challenges for breast reconstruction. There is no consensus regarding optimal timing for autologous reconstruction following radiation. This study explores clearly defined, shorter time intervals between completion of radiation and reconstruction than previously reported.

METHODS

 A retrospective review was performed on patients who underwent autologous reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Cohorts were selected by time elapsed between radiation and autologous reconstruction including <3 months, 3 to 6 months, 6 to 9 months, 9 to 12 months, 12 to 24 months, and >24 months. Analysis compared baseline characteristics, operative details, complications, revision rates, and BREAST-Q scores. Analysis of variance was used for continuous variables and chi-square for discrete variables.

RESULTS

 In total, 462 radiated patients underwent 717 flaps. There were 69 patients at <3 months (14.9%), 97 at 3 to 6 months (21%), 64 at 6 to 9 months (13.9%), 36 at 9 to 12 months (7.8%), 73 at 12 to 24 months (15.8%), and 123 at >24 months (26.6%). Age, time from mastectomy, and failure of primary reconstruction were higher at >24 months (p < 0.001). There was no difference between cohorts in intraoperative complications in radiated or nonradiated breasts. There was no difference in acute and late postoperative complications between cohorts. Wound-healing complications in radiated sides were lowest at <3 months and 3 to 6 months (5/69 [7.3%] and 11/97 [11.3%], respectively) compared with other groups (18.8-22.2%) but did not reach significance (p = 0.11). More fat graft revisions occurred at <3 months (p = 0.003).

CONCLUSION

 Reconstruction can be safely performed within 3 months after radiation without increases in intraoperative, acute, or late reconstructive complications.

Citation Analysis in Breast Reconstruction Publications Between 2000 and 2010

Introduction and Purpose: Breast reconstruction is an active area of plastic surgery research. Citation analysis allows for quantitative analysis of publications, with more citations presumed to indicate greater influence. We performed citation analysis to evaluate the most cited papers on breast reconstruction between 2000 to 2010 to identify contemporary research trends. Methods: The SCI-EXPANDED database was used to identify the 50 most cited papers. Data points included authorship, publication year, publication journal, study design, level of evidence, number of surgeons/institutions, center of surgery, primary outcome assessed, implant/flap/acellular dermal matrix/fat graft, acellular dermal matrix brand and use with implants/flaps, fat graft use with implants/flaps, unilateral/bilateral, one-/two-stage, immediate/delayed, number of patients/procedures, complications. Descriptive analysis of trends was performed based on results. Results: 20% of papers were published in 2006, 16% in 2007 and 12% in both 2004/2009. 66% were published in Plastic and Reconstructive Surgery. The majority were retrospective or case series, and of Level III or IV evidence. The one Level I study was a prospective multicenter trial. 21 and 7 papers discussed procedures by single/multiple surgeons, respectively. Results from single/multiple centers were discussed in 18 and 6 papers, respectively. 30 papers discussed implant-based reconstruction, 22 papers flap-based (19 microsurgical), 15 papers acellular dermal matrix, and five papers fat grafting. The primary focus in the majority was complications or outcomes. Conclusion: Our analysis demonstrates continually evolving techniques in breast reconstruction. However, there is notable lack of high quality evidence to guide surgical decision-making in the face of increasing surgical options.

Guideline Awareness Disparities in Plastic Surgery: A Survey of American Society of Plastic Surgeons

The American Society of Plastic Surgeons (ASPS) clinical practice guidelines were constructed to help direct evidence-based surgical management in plastic surgery. Societal member awareness of the recommendations for breast reconstruction has yet to be studied among ASPS members.

Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience

BACKGROUND

This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization.

METHODS

A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol.

RESULTS

Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001).

CONCLUSIONS

ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Influence of Irradiation on Capsules of Silicone Implants Covered with Acellular Dermal Matrix in Mice

BACKGROUND

In advanced breast cancer, radiotherapy is recommended as adjuvant therapy following breast reconstructive surgery. This inevitably led to growing concerns over possible complications of radiotherapy on implants. In this experimental animal study, we investigated the utility of acellular dermal matrix (ADM) wraps around implants as preventive management for radiotherapy complications.

METHODS

Black mice (C57NL6; n = 32) were assigned to groups that either received radiation or did not: groups A and B underwent surgery using implants without radiotherapy; while groups C and D underwent surgery using implants with radiotherapy for one and three months, respectively. The hemispheric silicone implants with an 0.8-cm-diameter were inserted on the left back of each mouse, and implants wrapped by ADM were inserted on the right back. The Clinic 23EX LINAC model was used for irradiation at 10 Gy. The samples were evaluated by gross assessment, histological analysis, immunohistochemical analysis, and the Western blotting test.

RESULTS

The H&E staining analysis showed that membrane thickness is smallest in group A, followed by groups C, D, and B. In a Masson trichrome histological analysis, collagen fibers became less dense and more widespread over time in the groups that received an ADM. Immunohistochemistry findings were similarly constant. However, the expression of TGF-β1 was increased in the irradiated groups, whereas it was decreased in the non-irradiated groups as observed over time.

CONCLUSIONS

Radiotherapy was shown to increase risk factors for capsular contracture, including inflammatory response, pseudoepithelium, thinning of membrane, and TGF-β1 expression over time; however, the accompanying framework using an ADM as a barrier between implant and tissue was shown to be effective in alleviating these risks.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 Failed Breast Implant in Postmastectomy Reconstruction: A Systematic Literature Review of Complications of Implant-Based Breast Reconstruction

BACKGROUND

Breast cancer is the most diagnosed malignant neoplasia of female patients worldwide in 2019. Survival has increased making it necessary to offer breast reconstructive procedures to improve quality of life and self-esteem. Implant-based breast reconstruction is the most common approach, making it necessary to quantify the associated complications.

METHODS

A systematic literature review of the PubMed, Cochrane, and Web of Science databases was performed. A total of 9608 citations were identified, and 44 studies met the inclusion criteria.

RESULTS

Studies included reported the incidence of complications either per patient or per breast leading consequently to 2 complication rates depending on the type of reporting. A total of 14.3% of patient-related and 28.8% of breast-related complications while undergoing implant-based reconstruction were reported.Among total complications reported, 72.6% of patient-related and 48.5% of breast-related complications were classified as major complications.A total of 37.6% of patients respectively 15.1% of breasts required prosthesis explantation due to severe complications. Depending on reporting, 9.7% of patients and 4% of breasts required autologous flap reconstruction due to reconstructive failure.

CONCLUSIONS

High complication and failure rates are associated with implant-based breast reconstruction. Lacking randomized controlled trials, the choice between implant-based and autologous breast reconstruction has to be made individually for each patient.

Imaging Surveillance of the Reconstructed Breast in a Subset of Patients May Aid in Early Detection of Breast Cancer Recurrence

Objectives:

The purpose of this study is to determine the biological markers more frequently associated with recurrence in the reconstructed breast, to evaluate the detection method, and to correlate recurrent breast cancers with the detection method.

Material and Methods:

An institutional review board-approved retrospective study was conducted at a single institution on 131 patients treated with mastectomy for primary breast cancer followed by breast reconstruction between 2005 and 2012. Imaging features were correlated with clinical and pathologic findings.

Results:

Of the 131 patients who met our inclusion criteria, 40 patients presented with breast cancer recurrence. The most common histopathologic type of primary breast cancer was invasive ductal carcinoma in 82.5% (33/40) of patients. Triple-negative breast cancer was the most common biological marker with 42.1% (16/38) of cases. Clinically, 70% (28/40) of the recurrences presented as palpable abnormalities. Of nine patients who underwent mammography, a mass was seen in eight patients. Of the 35 patients who underwent ultrasound evaluation, an irregular mass was found in 48.6% (17/35) of patients. Nine patients with recurrent breast cancer underwent breast MRI, and MRI showed an irregular enhancing mass in four patients, an oval mass in four patients, and skin and trabecular thickening in one patient. About 55% of patients with recurrent breast cancer were found to have distant metastases.

Conclusion:

Patients at higher risk for locoregional recurrence may benefit from imaging surveillance in order to detect early local recurrences.

Intensity Modulated Proton Therapy Treatment Planning for Postmastectomy Patients with Metallic Port Tissue Expanders

Purpose

Proton beam therapy can significantly reduce cardiopulmonary radiation exposure compared with photon-based techniques in the postmastectomy setting for locally advanced breast cancer. For patients with metallic port tissue expanders, which are commonly placed in patients undergoing a staged breast reconstruction, dose uncertainties introduced by the high-density material pose challenges for proton therapy. In this report, we describe an intensity modulated proton therapy planning technique for port avoidance through a hybrid single-field optimization/multifield optimization approach.

Methods and Materials

In this planning technique, 3 beams are utilized. For each beam, no proton spot is placed within or distal to the metal port plus a 5 mm margin. Therefore, precise modeling of the metal port is not required, and various tissue expander manufacturers/models are eligible. The blocked area of 1 beam is dosimetrically covered by 1 or 2 of the remaining beams. Multifield optimization is used in the chest wall target region with blockage of any beam, while single-field optimization is used for remainder of chest wall superior/inferior to the port.

Results

Using this technique, clinical plans were created for 6 patients. Satisfactory plans were achieved in the 5 patients with port-to-posterior chest wall separations of 1.5 cm or greater, but not in the sixth patient with a 0.7 cm separation.

Conclusions

We described a planning technique and the results suggest that the metallic port-to-chest wall distance may be a key parameter for optimal plan design.

Allograft vs Xenograft Bioprosthetic Mesh in Tissue Expander Breast Reconstruction: A Blinded Prospective Randomized Controlled Trial

BACKGROUND

With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs.

OBJECTIVES

The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction.

METHODS

A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed.

RESULTS

From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14).

CONCLUSIONS

Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction.

LEVEL OF EVIDENCE: 2

Acellular Dermal Matrix-Associated Contracture: A Clinical and Histologic Analysis of Patients Undergoing Prosthetic Breast Reconstruction

BACKGROUND

Capsular contracture is a well-recognized complication following prosthetic breast reconstruction. It has been the authors' observation that some patients undergoing breast reconstruction experience contracture specifically of the acellular dermal matrix placed at the time of their tissue expander insertion. The goal of the authors' study was to identify clinical and histologic findings associated with the development of acellular dermal matrix-associated contracture.

METHODS

The authors performed a retrospective cohort study of all patients undergoing bilateral implant-based breast reconstruction performed by the senior author (M.S.A.). Patients were excluded if they had radiation therapy to the breast. Patients with suspected acellular dermal matrix-associated contracture were identified by clinical photographs and review of operative notes. Histologic analysis was performed on specimens taken from two patients with acellular dermal matrix contracture.

RESULTS

The authors included a total of 46 patients (92 breasts), of which 19 breasts had suspected acellular dermal matrix-associated contracture. Acellular dermal matrix contracture was less common in direct-to-implant reconstruction (4.2 percent versus 26.5 percent; p = 0.020) and more common in breasts that had seromas (0 percent versus 15.8 percent; p = 0.001) or complications requiring early expander replacement. Contracted acellular dermal matrix had less vascularity and a lower collagen I-to-collagen III ratio, and was twice as thick as noncontracted acellular dermal matrix.

CONCLUSIONS

The authors have described a distinct phenomenon of acellular dermal matrix-associated contracture that occurs in a small subset of breasts where acellular dermal matrix is used. This merits further investigation. Future work will be required to better characterize the clinical factors that make acellular dermal matrix-associated contracture more likely to occur.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Tissue Expansion after Non-Skin-Sparing Mastectomy: A Comparative Study of Expansion Courses of Prepectoral and Subpectoral Tissue Expander Placement with Acellular Dermal Matrix

Although skin- or nipple-sparing mastectomy has been popular in the treatment of breast cancer, the radical excision of breast tissue is unavoidable in certain circumstances. However, the ability of an acellular dermal matrix (ADM) to expand remains questionable, and this situation may further hinder tissue expansion. From October 2017 to January 2020, patients who underwent immediate breast reconstruction with tissue expander placement using ADM whose initial fill volume was less than 50 mL were retrospectively reviewed. The primary outcomes were the number of visits and number of days required to complete the expansion, and the secondary outcomes were the amount of postoperative expansions, expander fill ratio and expander volume. Between the prepectoral group (n = 26) and subpectoral group (n = 39), the mean number of days (81.46 days versus 88.64 days, p = 0.365) and mean number of visits (5.08 versus 5.69, p = 0.91) required to complete expansion exhibited no significant differences. Additionally, there were no significant differences in the mean amount of postoperative expansion (314.23 mL versus 315.38 mL, p = 0.950), the mean final volume (353.08 mL versus 339.62 mL, p = 0.481) or the mean final volume ratio (0.89 versus 0.86, p = 0.35) between the two groups. Therefore, we suggest that prepectoral tissue expander placement after conventional mastectomy can be a valid option.

Outcomes and quality of life in immediate one-stage versus two-stage breast reconstructions without an acellular dermal matrix: 17- years of experience

BACKGROUND

Advantages of one-stage implant-based reconstructions include expedited surgery and recovery. This study aimed to investigate clinical and patient-reported outcomes in one-stage implant-based breast reconstructions without acellular dermal matrix (ADM).

METHODS

A prospectively collected database from 2002 to 2018 was retrospectively reviewed. One-stage and two-stage groups were compared for demographics, implant properties, early complications (hematoma, seroma, poor wound healing, implant removal), late complications (skin necrosis, capsular contracture, implant exposure, implant rupture), revision procedures, and Breast-Q questionnaire outcomes.

RESULTS

A total of 223 patients, 187 one-stage (84%) and 36 two-stage (16%) patients were recruited. At a mean follow-up of 124.9 and 92.5 months, respectively (p < .01), there were no differences in early (p = .85) or late (p = .23) complications or revision procedures (p = .12). Eighty patients (36%) returned the Breast-Q questionnaire (60 one-stage, 20 two-stage patients). There were no statistical differences in patient reported outcomes in breast well-being (p = .07), psychosocial well-being (p = .84), or sexual well-being (p = .78).

CONCLUSIONS

One-stage implant-based breast reconstruction without an ADM is a viable reconstruction providing comparable outcomes to two-stage procedures, with the benefit of minimal complications, a shorter reconstructive journey, and satisfactory quality of life.

A Study on Breast Reconstruction in a Developing Country: A Comprehensive Evaluation of the Techniques and Oncologic Outcomes

BACKGROUND

Breast cancer, with an incidence of 33.2 per 100,000 in Iranian population, is considered as the most common cancer in Iranian women. Nowadays, with the increasing survival rates, breast reconstruction has been integrated into surgical techniques of breast cancer treatment. The aim of this study was to evaluate the current status of breast reconstruction in Iranian population.

PATIENTS AND METHODS

This retrospective study was conducted in Imam Hospital between January 2008 and June 2018. All the patients underwent breast reconstruction surgery. The trend of reconstruction and complication rates were 2 major outcomes. Logistic regression model was used to predict complications. Student t test was used to compare means.

RESULTS

Fifty-five patients underwent 60 autologous breast reconstruction surgeries and 152 patients underwent 193 prosthesis-based reconstruction surgeries. Most of cases were invasive ductal carcinoma ± ductal carcinoma in situ (126 cases, 68%). Among 253 surgeries in 207 patients, 98 cases (38.7%) were 2-stage implant, 91 (36.0%) were 1-stage implant, 3 (1.2%) were acellular dermal matrix + prosthesis, 31 (12.2%) were pedicled transverse rectus abdominis myocutaneous flap, 25 (9.8%) were latissimus dorsi flap ± prosthesis, and 4 (15.8%) were latissimus dorsi flap. Among prosthesis-based reconstructions, chemotherapy could predict the occurrence of complications (odds ratio, 2.87; 95% CI, 1.07-7.68), whereas none of these factors could predict the occurrence of complications in autologous reconstructions. The most prevalent complication was seroma formation (48.5% of all complications). Overall complication rates (including major and minor) were higher among autologous reconstructions compared with prosthesis-based reconstructions (45.8% and 21.1%, respectively, P < 0.001).

CONCLUSIONS

The trend of breast reconstruction is changing in Islamic Republic of Iran as a developing country. Implant-based reconstruction has surpassed autologous reconstructions in recent years. In terms of complications, we observed higher rates among autologous reconstructions.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Laterality and Patient-Reported Outcomes following Autologous Breast Reconstruction with Free Abdominal Tissue: An 8-Year Examination of BREAST-Q Data

BACKGROUND

Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making.

METHODS

The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years.

RESULTS

Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively).

CONCLUSIONS

These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.

Complication Rate of Prepectoral Implant-based Breast Reconstruction Using Human Acellular Dermal Matrices

Implant-based breast reconstruction (IBR) is currently the most frequently performed reconstructive technique post mastectomy. Even though submuscular IBR continues to be the most commonly used technique, mastectomy technique optimization, the possibility to check skin viability with indocyanine green angiography, the enhanced propensity of patients undergoing prophylactic mastectomies, and the introduction of acellular dermal matrices (ADMs) have paved the way to the rediscovery of the subcutaneous reconstruction technique. The aim of this article is to update the complication rate of immediate and delayed prepectoral IBR using human ADMs (hADMs).

METHODS

A literature search, using PubMed, Medline, Cochrane, and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate complication rates of prepectoral implant-based reconstructions using hADMs. The following MeSH terms were used: "prepectoral breast reconstruction acellular dermal matrix," "prepectoral breast reconstruction ADM," "human ADM breast reconstruction," and "human acellular dermal matrix breast reconstruction" (period: 2005-2020; the last search took place on April 2, 2020).

RESULTS

This meta-analysis includes 1425 patients (2270 breasts) who had undergone immediate or delayed prepectoral IBR using different types of hADMs. The overall complication rate amounted to 19%. The most frequent complication was represented by infection (7.9%), followed by seroma (4.8%), mastectomy flap necrosis (3.4%), and implant loss (2.8%).

CONCLUSIONS

The overall complication rate was 19%. The most frequent complications were infection, seroma, and mastectomy flap necrosis, while capsular contracture was rare.

Effects of Prophylactic Lipofilling After Radiotherapy Compared to Non-Fat Injected Breasts: A Randomized, Objective Study

BACKGROUND

Patients who are suffering from invasive breast cancer may require post-mastectomy radiation therapy (PMRT). PMRT improves outcomes in breast cancer patients in terms of locoregional recurrence. Preliminary studies indicate that fat injections reduce post-radiation damage of soft tissue and implants.

OBJECTIVES

The aim of this study was to demonstrate the safety and effectiveness of prophylactic fat injections on radiated implanted breasts.

METHODS

The authors randomly assigned 60 female patients to either Group A or B. Group A patients received 3 breast fat injections, according to Coleman's technique, after radiotherapy and before expander removal with definitive implant insertion. Group B patients underwent surgery without lipofilling. At each surgical operation, skin biopsies were performed in a specific breast area to evaluate adipose tissue thickness, and a statistical analysis of the thickness variations was performed with the Wilcoxon's sum test. Disability was assessed according to the Late Effects of Normal Tissues-Subjective Objective Management Analytic scale.

RESULTS

The study demonstrates a qualitative and quantitative improvement about tissues after fat injection. This is highlighted by the significant increase in thickness after lipofilling.

CONCLUSIONS

The study, which is based on both clinical and histological findings and is supported by the comparison of a control group with a 1-year follow-up, demonstrates that fat injections reduce tissue radio damage, improving reconstructive surgery outcomes and quality of life.

LEVEL OF EVIDENCE: 2

Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume

Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series. Included in the study were 125 patients (217) with autologous breast reconstructions. Although DIEP flaps were the commonest flap used overall (79%), within in the low body mass index (<22) group, there was a greater use of Latissimus (32%), and thigh-based flaps (>50%).

Comparisons Between Normal Body Mass Index and Overweight Patients Who Underwent Unilateral Microsurgical Breast Reconstructions

BACKGROUND

This study compared the outcomes of unilateral microsurgical breast reconstructions using abdomen-based flaps between normal body mass index (BMI; 18.5 < BMI < 24.9 kg/m²) and overweight (25 < BMI < 29.9 kg/m²) patients.

METHODS

Between March 2000 and December 2015, patients who underwent unilateral breast reconstructions using abdomen-based flaps were retrospectively evaluated. Outcomes variables evaluated included the flap-used weight, flap-used/flap-harvested percentage, flap-used/specimen percentage, complication rates, revision procedures, and quality of life using the Breast-Q questionnaires.

RESULTS

A total of 415 patients with a mean age of 45.3 ± 8.2 years underwent 418 abdomen-based flaps. The overall success rate was 98.8%, with 99.1% and 97.9% of patients included in the normal BMI and overweight groups, respectively (p = 0.36). The mean flap-used weight and flap-used/flap-harvested values of 461 ± 132.1 g and 82.2 ± 11.6%, respectively, in the normal BMI group were statistically different from values of 610 ± 148.9 g and 71.4 ± 14.1% in the overweight group (both p < 0.01). The mean flap-used/specimen percentage was 118.5 ± 32.9 and 111.7 ± 36.6 in the normal BMI and overweight groups, respectively (p = 0.26). At a mean follow-up of 135 ± 55.4 months, there were no statistical differences between the two groups in terms of total complication rates (25.7% vs. 29.2%; p = 0.30), revision times (36.1% vs. 36.5%; p = 0.91) and all four domains (all p > 0.05) of the Breast-Q.

CONCLUSIONS

Patients with a normal BMI required a smaller flap-used weight but higher flap-used/flap-harvested percentage for unilateral microsurgical breast reconstructions that could be performed with a high success rate and comparable complication and revision rates.

Autologous tissue reconstruction after mastectomy-A cross-sectional survey of 110 hospitals in China

BACKGROUND

Autologous reconstruction after mastectomy became more and more popular, so this study aimed to obtain up-to-date and comprehensive data on autologous reconstruction in China.

METHODS

An electronic questionnaire was sent to 110 hospitals, which were chosen depending on geographical distribution and hospital types. The questionnaire investigated the demographics, characteristics, breast cancer treatment and reconstruction situation of these hospitals through different modules. We only focused on the autologous breast reconstruction module data.

RESULTS

96 hospitals have performed breast reconstruction surgery. The proportion of the hospital performing latissimus dorsi flap (LDF, N = 91), pedicle transverse rectus abdominis myocutaneous flap (pTRAM, N = 62), free abdominal flap (N = 43) and other kinds of flap decreased in sequence. Of the overall reconstruction cases, only 34.3% were autologous reconstruction and LDF was still the most popular option for autologous reconstruction. Related factors of hospital performing different procedures included years of performing breast reconstruction, breast surgical volume, and establishment of an independent plastic surgery department. Compared with LDF, abdominal breast reconstruction was associated with a higher flap necrosis rate.

CONCLUSIONS

This cross-sectional survey offers real-life autologous reconstruction information on a large population and covers the national surgical landscape in China. Autologous reconstruction is still an important part of breast reconstruction. Nevertheless, its low proportion and lower proportion of abdominal flap reconstruction in each institution, demonstrates that special training should be developed for breast surgeons and multidisciplinary cooperation would be promoted in the future.

Current Practice and Perceptions Regarding Cost Communication in Breast Cancer Reconstruction: Survey Results of the American Society of Plastic Surgeons

BACKGROUND

Rising out-of-pocket costs (OOCs) are a major concern for breast cancer survivors. However, information on how plastic surgeons performing breast reconstruction (BR) perceive and communicate cost information is limited.

METHODS

An electronic, anonymous survey eliciting plastic surgeons' attitudes and behaviors regarding BR cost communication was distributed to active American Society of Plastic Surgery members. Questions were derived from previously published studies and entailed a 5-point Likert scale. Cost communication was identified based on dichotomized responses to the prompt, "I discuss the costs of breast reconstruction with my patients," and analyzed for associated factors.

RESULTS

Of the 5112 surgeons surveyed, 396 plastic surgeons responded (7.21%). Most of the surgeons reported having a sense of a patient's financial well-being (65%) and an awareness of treatment costs (66.9%). Most felt a responsibility to consider the impact of BR costs (69%). Although most of the surgeons expressed that they were comfortable having OOC discussions (58.9%), only a minority reported doing so routinely (24.2%). The fewest respondents (8.6%) cited OOC as an important variable for BR decision-making. Lack of supportive tools was the most cited barrier to having cost communication with patients (64.8%). Cost communication was identified in a minority (20.2%) of surgeon-patient encounters and had no significant relationship to surgeon demographics or practice setting.

CONCLUSIONS

Plastic surgeons rarely discuss costs of BR with patients despite having a high awareness of the topic and feeling comfortable with it. Prevailing attitudes about the importance of OOC and the lack of administrative support or cost information are likely the drivers of this mismatch and warrant further study.

Implant-based Breast Reconstruction Outcomes Comparing Freeze-dried Aseptic Alloderm and Sterile Ready-to-use Alloderm

The use of acellular dermal matrix has revolutionized implant-based breast reconstruction in the 21st century. There have been a number of different dermal matrices introduced to clinical use and their equivalence has been debated. The purpose of this study is to examine a sequential series of acellular dermal matrix assisted implant-based breast reconstructions by a single surgeon and to compare the outcomes between a freeze-dried (FD) Alloderm cohort and a sterile ready to use Alloderm cohort.

Methods

After institutional review board approval, all consecutive implant-based breast reconstructions of a single surgeon (D.S.W.) from January 2009 to June 2016 were examined. Two hundred thirty-six patients received either FD Alloderm in the first 151 breasts reconstructed or sterile ready-to-use Alloderm in the last 227 breasts.

Results

The FD Alloderm patients had more tissue expander reconstructions performed and were all subpectoral placement. The ready-to-use Alloderm patients had more direct-to-implant procedures and some prepectoral placements. The complication rates were similar for seroma, hematoma, skin necrosis, and dehiscence. There were more infections, implant losses, and unexpected reoperations in the FD Alloderm group.

Conclusion

The rate of infection, explantation, and unexpected reoperation was lower in the sterile ready-to-use Alloderm group versus the FD Alloderm group.

Efficacy of Acellular Dermal Matrix in Capsular Contracture of Implant-Based Breast Reconstruction: A Single-Arm Meta-analysis

BACKGROUND

A large number of clinical studies have suggested that acellular dermal matrix (ADM) can decrease the incidence of capsular contracture in implant-based breast reconstruction. Yet, there is currently no high-level epidemiological evidence to prove this. The goal of this meta-analysis was to clarify the efficacy of ADM in capsular contracture, and provide a reference value for plastic surgeons.

METHODS

We systematically performed a search on PubMed, EMBASE, and the Cochrane Library to identify eligible studies from inception up to October 1, 2019. A random-effects model was used to obtain a pooled incidence rate. We conducted subgroup analysis according to geographic region, type of ADM, body mass index (BMI), duration of follow-up, and proportion of participants who have received radiotherapy.

RESULTS

A total of 18 studies involving 2941 cases were included. Overall, the pooled incidence rate of capsular contracture was 2.4% (95% CI 1.2-3.9%). The results from subgroup analyses indicated an even lower incidence in North America (1.6%, 95% CI 0.5-3.3%) and in human-derived ADM (HADM) (1.2%, 95% CI 0.2-3.0%). In addition, the results showed that the patients with BMI < 24, or who have received radiotherapy, were more prone to capsular contracture.

CONCLUSION

The application of ADM can effectively reduce the incidence of capsular contracture in implant-based breast reconstruction. And we infer that it might also apply to breast augmentation. However, additional high-quality trials are warranted to corroborate the findings of this meta-analysis.

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.

Unilateral Tissue Expander/Implant Two-Stage Breast Reconstruction with the Assistance of Three-Dimensional Surface Imaging

BACKGROUND

In China, traditional preoperative planning of unilateral breast reconstruction mainly depends on anthropometric measurement and visual assessment. Thus, the lack of objective assessment of breast volume and shape would likely result in suboptimal reconstruction outcomes. Three-dimensional surface imaging (3D-SI), which could provide objective measurement data of the breast, may be a promising solution to this problem.

METHODS

A retrospective review of patients undergoing tissue expander (TE)/implant breast reconstruction without any mammoplasty surgery on the contralateral sides in our hospital from August 2013 to May 2018 was performed. All the patients underwent unilateral mastectomy with immediate or delayed insertion of TE, followed by an exchange of a silicone gel implant without contralateral procedures. 3D images were obtained at the time of preoperation, the routine expansion visit, and post-exchange of implant. The breast volume measured by 3D-SI served as a guide to conduct the surgery management, such as in deciding the total volume of expansion and guiding the final implant size selection. 3D-SI also provided objective data to evaluate the final outcomes of the reconstruction.

RESULTS

Fifty-one patients were included in this study, in which eighteen patients underwent immediate TE insertion and thirty-three patients underwent delayed TE insertion. The ptosis degree of contralateral breasts was assessed as follows: forty-four were normal, and seven showed mild ptosis. The average expansion degree was controlled at 161.6% ± 14.1% compared to the contralateral breasts. The volume of implants exchanged had a strong linear correlation with the 3D volume of the contralateral breasts at the end of expansion (P < 0.01). The mean time of follow-up was 9.1 ± 6.6 months. There was only one patient who experienced TE leakage with secondary infection and received TE exchange. For the immediate reconstruction group, the overall breast symmetry improved at the completion of implant exchange (P < 0.01), with an average asymmetry of 5.3% ± 4.0% compared with 10.6% ± 6.1% initially. For the delayed reconstruction group, the reconstructed side achieved good volume symmetry to the contralateral side (P > 0.05). There was no significant difference in breast basal width between bilateral breasts post-reconstruction (P > 0.05).

CONCLUSION

3D-SI serves as a valuable adjunct by providing accurate 3D volume of breasts within TE/implant breast reconstruction in Chinese patients without obvious breast ptosis, which could facilitate surgeons to achieve good reconstructive outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Current practice and barriers of mesh-assisted implant-based breast reconstruction in China: A nationwide cross-sectional survey of 110 hospitals

BACKGROUND

The current National Practice Questionnaire of implant-based breast reconstruction (IBBR) (NPQi) was to assess the clinical practice of mesh-assisted IBBR in China.

METHODS

A questionnaire was mailed to 110 hospitals in China, which have more than 200 breast cancer operations performed in 2017. The survey mainly included questions on the type and timing of IBBR, questions about the use of TiLOOP® Bra and acellular dermal matrix (ADM) and the complications of IBBR.

RESULTS

IBBR was routinely carried out in 86.36% (95/110) hospitals. IBBR was the most frequently-used (65.7%, 4,296/6,534) BR after mastectomy with a median of 24 cases (IQR 7.5-65) in each hospital. TiLOOP® Bra and ADM were available in 49.5% and 33.7% hospitals, respectively. Hospitals with ADM offered were more likely to located in economically developed regions (65.6%), when compared with hospitals without any mesh offered (14/35, 40.0%, P = 0.036) and with only TiLOOP® Bra offered (16/28, 57.1%, P = 0.032). The surgery volume was largely variated from hospitals without any mesh offered (median 380 cases, IQR 304-550), with only TiLOOP® Bra offered (median 790 cases, IQR 439-1096, P = 0.001) and with ADM offered (median 797 cases, IQR 497-1528, P < 0.001). Higher proportion of one-stage mesh-augmented direct-to-implant BR and lower proportion of autologous BR were observed in hospitals with mesh offered. The reported major complications were similar between hospitals with or without mesh offered.

CONCLUSIONS

The NPQi has provided a valuable insight into the current practice of IBBR and mesh used in China. The introduction of mesh-assisted techniques has revolutionized the clinical practice.

Implant-based breast reconstruction with Artia™ tissue matrix

BACKGROUND

In 2015, Artia™ (LifeCell, NJ), a new porcine acellular dermal matrix (ADM), was introduced at our unit. As there is lack of clinical studies on its use in breast reconstruction, the purpose of this prospective study was to assess outcome data for patients who underwent Artia™-assisted breast reconstruction. We compared these data with those of other studies of non-human ADMs in widespread use from the literature.

METHODS

All consecutive patients who underwent Artia™-assisted breast reconstruction between July 2016 and February 2018 were identified. A prospective database was maintained, including data of patient demographics, type of reconstruction, type of implant, oncological data if applicable, complication rates and adjuvant treatment delays.

RESULTS

Fifty-one patients undergoing 83 implant-based breast reconstructions with Artia™ were included in the study. Of the 83 reconstructions, 62% were performed following risk-reducing mastectomy, 28% following therapeutic mastectomy and 10% for revision procedures. After a mean 276-day follow-up period, the overall complication rate was 10.8%, including 6 breasts (7.2%) developing seromas requiring aspiration, 1 breast developing a haematoma (1.2%) and 2 implant losses (2.4%) in a single patient following neo-adjuvant chemotherapy. There were no cases of wound dehiscence or erythema/red breast syndrome.

CONCLUSION

This is one of the first studies demonstrating that Artia™-assisted implant-based breast reconstruction is associated with low and acceptable early complication rates. The results are promising and are comparable to our experience using established ADMs, with an implant loss rate of 4.9% across 500 ADM-assisted implant reconstructions.

Surgeon-Controlled Comparison of Direct-to-Implant and 2-Stage Tissue Expander-Implant Immediate Breast Reconstruction Outcomes

BACKGROUND

Current literature comparing outcomes of immediate breast reconstruction using direct-to-implant (DTI) single-stage and 2-stage tissue expanders (TEs) is conflicting. This study compared overall outcomes and determined predictive patient factors associated with higher complication rates.

METHODS

After institutional review board approval, a retrospective cohort study of consecutive patients who underwent immediate breast reconstruction from 2010 to 2014 at a single hospital was performed. Demographic data and complications were recorded and compared using univariate analysis. Infection was defined as any patient receiving antibiotics beyond the expected postoperative course or restarting antibiotics for a suspected infection.

RESULTS

Seventy-nine breasts (50 patients) underwent immediate breast reconstruction using tissue expansion, and 117 breasts (69 patients) underwent immediate breast reconstruction using the DTI technique. Overall complications, infection rate, and rate of aesthetic revisions were higher in the TE group compared with the DTI group. There was no difference in rates of seroma, hematoma, and mastectomy skin flap necrosis between the 2 groups. Infectious complications were significantly higher in patients with body mass index of greater than 30 who underwent TE-based reconstruction than those who underwent DTI-based reconstruction.

CONCLUSIONS

Single-stage DTI immediate breast reconstruction has less overall complications than 2-stage TE-based immediate reconstruction. Direct-to-implant immediate breast reconstruction may provide favorable outcomes in patients with body mass index of greater than 30.

Cost-Effectiveness Analysis of Silicone versus Saline Implant-Based Breast Reconstruction Using the BREAST-Q

BACKGROUND

The most common type of breast reconstruction is implant-based breast reconstruction. Implant-based reconstruction has been reported to impact quality-of-life outcomes. Therefore, the authors sought to evaluate the cost-effectiveness of saline versus silicone implants.

METHODS

The authors retrospectively reviewed data from patients who underwent breast reconstruction with saline or silicone implants at their institution. This included type of procedure, acellular dermal matrix use, complications, and number of revisions. Costs were estimated using the Centers for Medicare and Medicaid Services physician fee schedule and hospital costs. Effectiveness was measured using BREAST-Q-adjusted life-years, a measure of years of perfect breast health, based on BREAST-Q data collected before mastectomy and reconstruction and at 12 months after final reconstruction. The incremental cost-effectiveness ratio was obtained for silicone and saline reconstruction.

RESULTS

The authors identified 134 women, among which 77 (57 percent) underwent silicone and 57 (43 percent) underwent saline breast reconstruction. The cost of saline reconstruction was $1288.23 less compared with silicone. BREAST-Q-adjusted life-years were 28.11 for saline and 23.57 for silicone, demonstrating higher cost-effectiveness for saline. The incremental cost-effectiveness ratio for saline was -$283.48, or $283.48 less per year of perfect breast-related health postreconstruction than silicone.

CONCLUSIONS

The authors' results indicate that saline breast reconstruction may be more cost-effective compared with silicone at 12 months after final reconstruction. Silicone was both more expensive and less effective than saline. However, given the relatively small cost difference, surgeon and patient preference may be important in determining type of implant used.

Would Plastic Surgeons Choose Breast Conservation Therapy?

BACKGROUND

Breast conservation therapy is defined as partial mastectomy with subsequent radiation therapy and is the treatment for early-stage breast cancer. However, the unwanted risks of radiation must be considered as well as the impact on future breast reconstruction options. The purpose of this study was to assess the preference of plastic surgeons when given the hypothetical diagnosis of breast cancer.

METHODS

A survey assessing treatment preference of 3 hypothetical breast cancer diagnosis scenarios was designed and distributed by American Society of Plastic Surgeons via e-mail invite to its members.

RESULTS

The risk of cancer recurrence was the most common reason for treatment preferences of all three choices. However, for ductal carcinoma in situ, unilateral mastectomy with implant-based reconstruction is the preferred option with the second most influential reason of avoiding the risks of radiation therapy. For invasive ductal carcinoma node negative, unilateral mastectomy with implant-based reconstruction was the preferred option also due to risks of radiation therapy and anxiety of future surveillance. For invasive ductal carcinoma node positive, bilateral mastectomy with implant-based reconstruction was the preferred choice because of anxiety of future surveillance and also risks of radiation therapy.

CONCLUSIONS

In general, plastic surgeons did not prefer breast conservation therapy for in situ and early-stage breast cancer. Although the most common rationale for total mastectomy was risk of cancer recurrence for all disease severity, risks of radiation therapy are real and play an integral role in the decision-making process. In understanding our own biases, we can help better empathize with patients in consultation for breast reconstruction.

Cutaneous complications associated with breast augmentation: A review

Breast augmentation is one of the most popular and safe cosmetic procedures performed by plastic surgeons worldwide. Although breast implants are available in a number of different materials, silicone-filled implants remain the most common type. However, prior to the development of breast implants, various materials were injected into the soft tissues of the breasts to increase breast volume, which caused cutaneous complications and disfigurement. This review details the history of breast augmentation, the current methods used in augmentation surgery, and associated cutaneous complications.

Outcomes of Acellular Dermal Matrix for Immediate Tissue Expander Reconstruction with Radiotherapy: A Retrospective Cohort Study

BACKGROUND

Despite increasing literature support for the use of acellular dermal matrix (ADM) in expander-based breast reconstruction, the effect of ADM on clinical outcomes in the presence of post-mastectomy radiation therapy (PMRT) has not been well described.

OBJECTIVES

To analyze the impact ADM plays on clinical outcomes on immediate tissue expander (ITE) reconstruction undergoing PMRT.

METHODS

We retrospectively reviewed patients who underwent ITE breast reconstruction from 2004 to 2014 at MD Anderson Cancer Center. Patients were categorized into four cohorts: ADM, ADM with PMRT, non-ADM, and non-ADM with PMRT. Outcomes and complications were compared among cohorts.

RESULTS

Over 10 years, 957 patients underwent ITE reconstruction (683 non-ADM, 113 non-ADM with PMRT, 486 ADM, and 88 ADM with PMRT) with 1370 reconstructions. Overall complication rates for the ADM and non-ADM cohorts were 39.0% and 16.7%, respectively (P < 0.001). Within both cohorts, mastectomy skin flap necrosis (MSFN) was the most common complication, followed by infection. ADM use was associated with a significantly higher rate of infections and seromas in both radiated and non-radiated groups; however, when comparing radiated cohorts, the incidence of explantation was significantly lower with the use of ADM.

CONCLUSIONS

The decision to use ADM for expander-based breast reconstruction should be performed with caution, given higher overall rates of complications, including infections and seromas. There may, however, be a role for ADM in cases requiring PMRT, as the overall incidence of implant failure is lower than non-ADM cases.

LEVEL OF EVIDENCE: 3

[Acellular dermal matrix and synthetic mesh in implant-based immediate breast reconstruction: Current concepts]

The use of acellular dermal matrices and synthetic meshes is gaining popularity in direct-to-implant breast reconstruction, allowing the complete coverage of the prosthesis with greater pocket control and improved cosmesis. In this concise review, we present the advantages of acellular dermal matrices and resorbable or nonresorbable synthetic meshes in implant-based breast reconstruction, we discuss the risk of postoperative complications, and we raise their contribution in the growing interest of prepectoral breast reconstruction.

Managing Postoperative Infection following Breast Reconstruction with the Sientra AlloX2 Tissue Expander

Supplemental Digital Content is available in the text.

Background:

Implant-based breast reconstruction is the most common reconstructive modality in the United States. Significant advances in surgical technique and technology have resulted in improvement of clinical outcomes. A recent innovation has been the introduction of a tissue expander with an integral drain that permits access to the periprosthetic space. A new use for this drain port is presented in patients with postoperative surgical-site infection.

Methods:

Patients who underwent staged implant-based breast reconstruction with the Sientra AlloX2 tissue expander and experienced postoperative infection that warranted inpatient management with intravenous antibiotics were included in the study. The integral drain port was used in these patients to perform washout of the periprosthetic space at the bedside. The ability to salvage the tissue expander in the setting of infection without the need for surgical revision in the operating room was determined.

Results:

Of 31 patients who underwent a total of 52 staged breast reconstructions with the Sientra AlloX2 tissue expander, 3 patients (8.7%) with a mean age of 50.3 years (range, 34–76 years) and mean body mass index of 23.3 kg/m² (range, 22.3–24.1 kg/m²) met inclusion criteria. Salvage of the device with successful progression through expansion and eventual expander-implant exchange was achieved in 2 patients. One patient failed the salvage attempt and required removal of the device.

Conclusion:

Using the integral drain port of the AlloX2 tissue expander has the potential for device salvage in a subset of patients with surgical-site infection without the need for surgical revision.

Do Academic Health Care Systems Really Value Education? A Survey of Academic Plastic Surgeons

BACKGROUND

Although education is critical to the mission of academic medical centers in the United States, it is often not quantified and monetized as are their research and clinical missions. We undertook this survey to assess the perceived valuation of educational endeavors of plastic surgeon faculty at the U.S. academic medical centers.

METHODS

A survey using Qualtrics software (Qualtrics, Provo, UT) was distributed to faculty members of the American Council of Academic Plastic Surgeons by electronic mail in February 2015. A total of 16 questions included both demographic information and Likert-item questions of perception of valuation of educational activities. For analysis, responses were grouped according to an adapted Net Promoter Score including "unsupportive" (0-6), "neutral" (7-8), and "supportive" (9-10).

RESULTS

Sixty-five surveys were completed out of a total of 406, with an overall response rate of 16%. Kruskal-Wallis statistical analysis demonstrated that region and rank were not significant in perception of hospital or departmental support for educational activities. Respondents rated their departments as more supportive than their institutions (P < 0.05), and average perceived value rating of institutions was "unsupportive." Financial support was associated with higher ratings with respect to support of institutions and departments. Mid-career faculty displayed a trend toward lower ratings of perception of support.

CONCLUSIONS

The majority of respondents perceived their institutions and departments as unsupportive of educational effort. Direct compensation to physicians for teaching efforts may improve faculty retention in academia and reduce physician burnout.

Breast reconstruction statistics in Korea from the Big Data Hub of the Health Insurance Review and Assessment Service

BACKGROUND

Previously, surveys have been used to investigate breast reconstruction statistics. Since 2015, breast reconstruction surgery after mastectomy has been covered by the National Health Insurance Service in Korea, and data from breast reconstruction patients are now available from the Health Insurance Review and Assessment Service (HIRA). We investigated statistics in breast reconstruction in Korea through statistics provided by the HIRA Big Data Hub.

METHODS

We investigated the number of cases in mastectomy and breast reconstruction methods from April 1, 2015 to December 31, 2016. Data were furnished by the HIRA Big Data Hub and accessed remotely online. Results were tabulated using SAS Enterprise version 6.1.

RESULTS

The 31,155 mastectomy cases included 7,088 breast reconstruction cases. Implantbased methods were used in 4,702 cases, and autologous methods in 2,386. The implantbased reconstructions included 1,896 direct-to-implant and 2,806 tissue-expander (2-stage) breast reconstructions. The 2-stage tissue-expander reconstructions included 1,624 expander insertions (first stage) and 1,182 expander-to-permanent-implant exchanges (second stage). Of the autologous breast reconstructions, 705 involved latissimus dorsi muscle flaps, 498 involved pedicled transverse rectus abdominis myocutaneous (TRAM) flaps, and 1,183 involved free-tissue transfer TRAM flaps, including deep inferior epigastric perforator free-tissue transfer flaps. There were 1,707 nipple-areolar complex reconstructions, including 1,565 nipple reconstructions and 142 areola reconstructions. The 1-year mean number of breast reconstructions was 4,050.

CONCLUSIONS

This was the first attempt to evaluate the total number of breast reconstruction procedures using accurate, comprehensive data, and our findings may prove valuable as a foundation for future statistical studies of breast reconstruction procedures in Korea.

Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study

PURPOSE

Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions.

METHODS

A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed.

RESULTS

A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511).

CONCLUSIONS

A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.

Modeling of the metallic port in breast tissue expanders for photon radiotherapy

The purpose of this study was to model the metallic port in breast tissue expanders and to improve the accuracy of dose calculations in a commercial photon treatment planning system (TPS). The density of the model was determined by comparing TPS calculations and ion chamber (IC) measurements. The model was further validated and compared with two widely used clinical models by using a simplified anthropomorphic phantom and thermoluminescent dosimeters (TLD) measurements. Dose perturbations and target coverage for a single postmastectomy radiotherapy (PMRT) patient were also evaluated. The dimensions of the metallic port model were determined to be 1.75 cm in diameter and 5 mm in thickness. The density of the port was adjusted to be 7.5 g/cm³ which minimized the differences between IC measurements and TPS calculations. Using the simplified anthropomorphic phantom, we found the TPS calculated point doses based on the new model were in agreement with TLD measurements within 5.0% and were more accurate than doses calculated based on the clinical models. Based on the photon treatment plans for a real patient, we found that the metallic port has a negligible dosimetric impact on chest wall, while the port introduced significant dose shadow in skin area. The current clinical port models either overestimate or underestimate the attenuation from the metallic port, and the dose perturbation depends on the plan and the model in a complex way. TPS calculations based on our model of the metallic port showed good agreement with measurements for all cases. This new model could improve the accuracy of dose calculations for PMRT patients who have temporary tissue expanders implanted during radiotherapy and could potentially reduce the risk of complications after the treatment.