National Trends in Immediate Breast Reconstruction: An Analysis of Implant-Based Versus Autologous Reconstruction After Mastectomy

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.

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.

HoloDIEP-Faster and More Accurate Intraoperative DIEA Perforator Mapping Using a Novel Mixed Reality Tool

BACKGROUND

 Microsurgical breast reconstruction using abdominal tissue is a complex procedure, in part, due to variable vascular/perforator anatomy. Preoperative computed tomography angiography (CTA) has mitigated this challenge to some degree; yet it continues to pose certain challenges. The ability to map perforators with Mixed Reality has been demonstrated in case studies, but its accuracy has not been studied intraoperatively. Here, we compare the accuracy of "HoloDIEP" in identifying perforator location (vs. Doppler ultrasound) by using holographic 3D models derived from preoperative CTA.

METHODS

 Using a custom application on HoloLens, the deep inferior epigastric artery vascular tree was traced in 15 patients who underwent microsurgical breast reconstruction. Perforator markings were compared against the 3D model in a coordinate system centered on the umbilicus. Holographic- and Doppler-identified markings were compared using a perspective-corrected photo technique against the 3D model along with measurement of duration of perforator mapping for each technique.

RESULTS

 Vascular points in HoloDIEP skin markings were -0.97 ± 6.2 mm (perforators: -0.62 ± 6.13 mm) away from 3D-model ground-truth in radial length from the umbilicus at a true distance of 10.81 ± 6.14 mm (perforators: 11.40 ± 6.15 mm). Absolute difference in radial distance was twice as high for Doppler markings compared with Holo-markings (9.71 ± 6.16 and 4.02 ± 3.20 mm, respectively). Only in half of all cases (7/14), more than 50% of the Doppler-identified points were reasonably close (<30 mm) to 3D-model ground-truth. HoloDIEP was twice as fast as Doppler ultrasound (76.9s vs. 150.4 s per abdomen).

CONCLUSION

 HoloDIEP allows for faster and more accurate intraoperative perforator mapping than Doppler ultrasound.

Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?

INTRODUCTION

Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described.

OBJECTIVE

We aimed to compare the costs of eOBCS and mastectomy.

METHODS

We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included.

RESULTS

Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416.

CONCLUSION

eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.

Ten-year trend analysis of breast cancer, oncoplastic, and reconstructive breast surgery in a single institution (2010-2019), what has not changed?

PURPOSE

There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period.

METHODS

The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria.

RESULTS

The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%.

CONCLUSION

No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery

INTRODUCTION

Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions.

METHODS

All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared.

RESULTS

Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01).

CONCLUSIONS

This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Impact of the withdrawal of macrotextured implant on reconstruction practices

INTRODUCTION

On 22 November 2018, the French Society for Plastic, Reconstructive and Aesthetic Surgery recommended that Allergan® macrotextured breast implants be recalled, a decision endorsed by the French national health products safety agency (ANSM) on 2nd April 2019. At the Georges-François Leclerc Cancer Center (CGFL) in Dijon, we decided to stop using macrotextured implants as of November 2018 in favor of smooth implants. The purpose of this study is to evaluate the impact of the recall of macrotextured implants on breast reconstruction surgical practices and their complications.

METHODS

This is a single-centre, retrospective study performed at the CGFL in Dijon, France. Reconstruction techniques and complications were compared between two periods, i.e. before the recall of macrotextured breast implants (period 1: 1st September 2017-November 22, 2018) and after the recall (period 2: 23 November 2018-31st March 2020). All patients who underwent breast reconstruction for the first time were included.

RESULTS

Data were collected from 168 reconstructions in period 2, and 159 in period 2. The rate of use of breast implants during reconstructions decreased significantly in period 2 (53.6% vs. 23.9%; P<0.001). The rate of autologous reconstructions increased significantly for muscle sparing latissimus dorsi (2.4% vs. 12.6%; P<0.001) and exclusive fat grafting (9.5% vs. 21.5%; P<0.01). Clavien-Dindo Stage IIIb complications decreased in period 2 (10% vs. 18.4%; P=0.04).

CONCLUSION

Since the recall of macrotextured breast implants, the reconstruction rate has decreased in our centre in favor of autologous techniques with lower complication rates.

Novel single-centre experience - evaluation of outcomes post-implementation of a coordinated combined breast reconstruction service

BACKGROUND

Autologous breast reconstruction services are logistically complex and challenging to implement but have better outcomes than implants. This study aimed to evaluate the effect of implementing a coordinated, low-cost combined breast reconstruction service (0.8 FTE nurse liaison, 0.25 FTE plastic surgeon, two dedicated breast surgeons 0.05 FTE each and protected weekly all-day oncoplastic theatre) on unit productivity and efficiency in reducing wait times for immediate autologous breast reconstruction.

METHODS

A retrospective cohort study was conducted on all patients who underwent immediate autologous breast reconstruction at Fiona Stanley Hospital between two study periods, pre-intervention - February 2016 to June 2019 and post-intervention - November 2022. Data were analysed using SPSS v.27.

RESULTS

One hundred twenty-seven participants were included, with 49% (n = 62) in the post-intervention group. Most procedures performed were therapeutic (n = 108, 85%). DIEP was the most common flap (84%), and the mean BMI was 26.9 (SD ± 4.2). There was a statistically significant increase in the number of high-risk gene carriers' prophylactic cases and bilateral cases performed post-intervention (5% to 26%, P = 0.001) and (29% to 55%, P = 0.003), respectively. Time to surgery on the waitlist did not significantly change after the intervention (therapeutic group: 3.1 to 3.5 weeks, P = 0.821; prophylactic group: 55.0 to 61.1 weeks, P = 1.000). Overall, there was a marked increase in the overall productivity of the breast service unit in terms of mastectomies, total reconstructions, and autologous reconstructions performed.

CONCLUSIONS

This single-centre experience showed that implementing a coordinated service significantly increased the unit's productivity. This low-cost intervention can be applied to other healthcare settings.

Applying unsupervised machine learning approaches to characterize autologous breast reconstruction patient subgroups: an NSQIP analysis of 14,274 patients

BACKGROUND

Autologous breast reconstruction is composed of diverse techniques and results in a variety of outcome trajectories. We propose employing an unsupervised machine learning method to characterize such heterogeneous patterns in large-scale datasets.

METHODS

A retrospective cohort study of autologous breast reconstruction patients was conducted through the National Surgical Quality Improvement Program database. Patient characteristics, intraoperative variables, and occurrences of acute postoperative complications were collected. The cohort was classified into patient subgroups via the K-means clustering algorithm, a similarity-based unsupervised learning approach. The characteristics of each cluster were compared for differences from the complementary sample (p < 2 ×10-4) and validated with a test set.

RESULTS

A total of 14,274 female patients were included in the final study cohort. Clustering identified seven optimal subgroups, ordered by increasing rate of postoperative complication. Cluster 1 (2027 patients) featured breast reconstruction with free flaps (50%) and latissimus dorsi flaps (40%). In addition to its low rate of complications (14%, p < 2 ×10-4), its patient population was younger and with lower comorbidities when compared with the whole cohort. In the other extreme, cluster 7 (1112 patients) almost exclusively featured breast reconstruction with free flaps (94%) and possessed the highest rates of unplanned reoperations, readmissions, and dehiscence (p < 2 ×10-4). The reoperation profile of cluster 3 was also significantly different from the general cohort and featured lower proportions of vascular repair procedures (p < 8 ×10-4).

CONCLUSIONS

This study presents a novel, generalizable application of an unsupervised learning model to organize patient subgroups with associations between comorbidities, modality of breast reconstruction, and postoperative outcomes.

Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit

BACKGROUND AND OBJECTIVES

Immediate breast reconstruction (IBR) represents a fundamental part in the management of patients receiving mastectomy. In recent years, there has been an increasing trend in the use of IBR in all age groups. The study aims were to evaluate the age-specific trend of IBR, and to discuss its effects in work organization at an Italian Breast Unit.

METHODS

We searched for women diagnosed with breast cancer between 2010 and 2019, focusing on IBR rates in patients who received mastectomy. Age-specific trends were assessed using the Cochrane-Armitage test. Differences in operative times and hospital stay between women undergoing mastectomy + IBR (Ma + IBR) or mastectomy alone (Ma) were evaluated by Student's t test or χ2 test.

RESULTS

Among 1915 patients, 62.4% underwent breast conserving surgery (BCS), and 37.6% mastectomy. Overall, rates of Ma + IBR increased from 32% in 2010 to 58% in 2019 (p < 0.001). Although rates of IBR rose in all age groups, the trend was significantly increased among patients aged 50-59 (p < 0.001), 60-69 (p < 0.0001), and 70-79 (p < 0.05).

CONCLUSIONS

Rates of Ma + IBR have increased over years, especially among older women. Ma + IBR resulted in longer operative times and hospital stay than Ma alone. These findings imply that, in the near future, resources should be implemented to improve and strengthen the surgical activity of Breast Units, to support the increasing use of IBR in women of all age groups.

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.

Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management

BACKGROUND

Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning.

METHODS

This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications.

RESULTS

In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time.

CONCLUSIONS

Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Analysis of online materials regarding DIEP and TRAM flap autologous breast reconstruction

Online resources have become a mainstay for health information, and it is vital that such resources maintain accessible literacy levels to empower informed decision making. Previous studies have shown that the online resources regarding post-mastectomy breast reconstruction are of low readability; however, none have evaluated specific online resources regarding the most common procedures within autologous breast reconstruction, limiting analysis to the results of generic searches. This study sought to discover the readability of online, patient-directed resources regarding the Deep Inferior Epigastric Perforator (DIEP) and Transverse Rectus Abdominis Muscle (TRAM) flaps, the most utilized autologous flaps in breast reconstruction, using health literacy analysis. We hypothesized that the online materials regarding DIEP and TRAM flaps would yield literacy scores above the 6th-grade reading level, as recommended by the American Medical Association, despite previous literature and readability recommendations. Google searches for "DIEP breast reconstruction" and "TRAM breast reconstruction" were conducted. All patient-directed, non-sponsored websites found within the first three pages of the search underwent analysis using a variety of readability formulae. Both DIEP and TRAM resources were well above the 6th-grade reading level according to every metric used, and there was no significant difference in the reading level between the two procedures. Based on these results, significant work was needed to simplify the online resources to be more understandable for patients; these authors propose one method for such. In addition, the low readability of online resources suggests added emphasis on the need for surgeons to ensure that patients understand the medical information discussed during the presurgical consultations.

Breast Surgical Oncology Epidemiologic Research: A Guide and Comparison of Four National Databases

BACKGROUND

National databases are a rich source of epidemiologic data for breast surgical oncology research. However, these databases differ in the demographic, surgical, and oncologic variables provided. This study aimed to compare the strengths and limitations of four national databases in the context of breast surgical oncology research.

METHODS

The study comprised a descriptive analysis of four national databases (the National Surgical Quality Improvement Program [NSQIP], the Nationwide Inpatient Sample [NIS], the Surveillance, Epidemiology and End Results [SEER] program, and the National Cancer Database [NCDB]) to assess their strengths and limitations in the context of breast surgical oncology. The study assessed the data available in each database for female patients with a breast cancer diagnosis between 2007 and 2017, and compared patient age, ethnicity, and race distributions.

RESULTS

Data from 3.9 million female patients were examined, with most patients being between 60 and 69 years of age, non-Hispanic, and white. Age, ethnicity, and race distributions were similar in the databases. The NSQIP includes data on operative details, comorbidities, and postoperative outcomes. The NIS provides health services and inpatient utilization information, but does not evaluate outpatient procedures. The SEER program provides population-based oncologic detail including stage, histology, and neoadjuvant/adjuvant treatment. The NCDB offers hospital-based oncologic information and the largest population in the study period, with approximately 2.5 million breast cancer patients.

CONCLUSION

Epidemiologic datasets offer tremendous potential for the examination of oncologic breast surgery, with each database providing unique data useful for addressing different epidemiologic questions. Understanding the strengths and limitations of each database creates a more efficient and productive research environment.

Direct-to-Implant Subcutaneous Breast Reconstruction: A Systematic Review of Complications and Patient's Quality of Life

BACKGROUND

The use of direct-to-implant subcutaneous breast reconstruction has increased over the last years. The goal of this systematic review is to deliver an updated review of the safety of this technique and its impact on quality of life. We also compare subcutaneous vs submuscular complications, through meta-analysis.

METHODS

Literature review through PubMed and Cochrane Library databases were performed by PRISMA criteria. Thirty-nine studies met inclusion criteria for subcutaneous review and 15 studies met inclusion criteria for meta-analysis. All included studies were evaluated for complications and answers to the BREAST-Q. Data were analysed using Microsoft Excel, IBM SPSS, and Cochrane RevMan.

RESULTS

In 2863 patients and 3988 breasts that undergone direct to implant subcutaneous breast reconstruction, 8,21% had rippling, 5,64% seroma, 1,74% hematoma, 3,40% infection, 3,01% wound dehiscence, 3,93% skin necrosis, 3,34% nipple-areolar-complex (NAC) necrosis, 3,07% capsular contracture, 0,00% animation deformity, and 3,83% an implant removal. Meta-analysis showed a statistically significant decrease in the odds ratio of animation deformity, a but statistically significant higher odds ratio of rippling. Subcutaneous and submuscular reconstructions had similar BREAST-Q scores.

CONCLUSIONS

Direct-to-implant subcutaneous breast reconstruction does not harm the patient's quality of life, comparatively with submuscular, saving the pectoral muscle from dissection and preventing animation deformity, but increasing the risk of rippling.

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 .

Racial disparities in postmastectomy breast reconstruction following implementation of the affordable care act: A systematic review using a minority health and disparities research framework

BACKGROUND

This systematic review assesses racial disparities for African American (AA) women in breast reconstruction following the implementation of the Affordable Care Act.

METHODS

Four databases (Ovid Medline, PubMed, Scopus, Web of Science) were searched for peer-reviewed articles published between January 2011 and September 2021.

RESULTS

Out of 917 screened articles, 61 were included. The most common metrics were breast reconstruction rates (57.4%) and clinical outcomes (14.8%). Pooled reconstruction rates were 45.7% in white and 38.5% in AA women. 95.1% of studies found disparities in breast reconstruction rates. The greatest influencers on reconstruction rates were individual interactions in the healthcare system (54%), sociocultural environment (39%), behavioral factors (31%), and community interactions with the healthcare system (36%).

CONCLUSION

Racial disparities in postmastectomy breast reconstruction persist. Focusing on implicit bias, communication barriers and infrastructure are the most promising strategies to create equitable access to breast reconstruction for AA women.

Immediate surgical mesh-free implant-based breast reconstruction with fascial flap in breast cancer patients after mastectomy

PURPOSE

Surgical meshes are often used in retro-pectoral implant-based breast reconstruction (IBBR) to improve lower pole expansion. However, using of surgical meshes is associated with increased complications and costs. To solve this problem, we have adopted a modified fascia-based IBBR technique using fasciae of pectoral major, serratus anterior, and external oblique muscles to form a sling covering the lower pole of prosthesis since 2014.

METHODS

Data of 788 retro-pectoral IBBR cases, including 250 fascia-based IBBR cases (fascial group) and 538 traditional IBBR cases (control group), treated between 2014 and 2019 were retrospectively analyzed. The surgical outcomes of the fascial and control group were compared. The primary endpoint was the rate of post-operative complications requiring interventions. The secondary endpoint was the rate of explantation. The exploratory endpoint was the time from surgery to complication and explantation.

RESULTS

The fascial group had significantly lower rates of developing major post-operative complications (1.2 vs. 6.1%, p = 0.002) and losing prostheses (1.2 vs. 4.3%, p = 0.025), as compared with the control group. The median time from surgery to complication and explantation were 61 (range, 35-115) days and 92 (range, 77-134) days for the fascial group and 35 (range, 6-239) days and 63 (range, 23-483) days for the control group, respectively.

CONCLUSION

Fascia-based IBBR technique had low rates of major post-operative complications and explantation. Fascia-based IBBR technique could be considered as an alternative reconstruction method in properly selected patients.

Endoscopic Nipple- or Skin-Sparing Mastectomy and Immediate Breast Reconstruction with Endoscopic Harvesting of the Latissimus Dorsi Flap: A Preliminary Experience of an Innovative Technique

Background

Endoscopic nipple- or skin-sparing mastectomy (E-N/SSM) and endoscopic latissimus dorsi muscle flap (E-LDMF) harvest have been operational difficulties over decades. The aim of this study was to describe the preliminary outcomes of our novel surgical technique, which allows the performance of E-N/SSM and E-LDMF harvest for immediate breast reconstruction (IBR) through a single cosmetic axillary incision for breast cancer patients.

Methods

This prospective study included 20 breast cancer patients who underwent E-N/SSM and E-LDMF harvesting through a single axillary incision in our hospital from September 2020 to June 2022. The outcomes were statistically calculated, including patient characteristics, operative data, complication rate, hospital length of stay and costs, and patient-reported outcomes.

Results

A total of 20 breast cancer patients underwent our sufficiently mature novel endoscopy technique. The mean LD flap harvest time was 96.5 ± 25.3 min, the mean operation time was 262.6 ± 54.4 min, and the average length of LDMF was 26.9 ± 3.1. During the median follow-up time of 7.5 months, 4 patients developed donor-site seroma. One of them was also complicated by hypopigmentation of the nipple areola, and one of them suffered from breast cellulitis. No bleeding or flap necrosis happened. No tumor recurrence or metastasis was found until the last follow-up. In the BREAST-Q evaluation, although they gave a lower score beginning at 1-month post-operation than preoperatively (P > 0.05, except for physical well-being: chest and physical well-being: back and shoulder, P < 0.01), there was an uptrend at 3 months postoperatively. Because of the hidden and short incision, the mean score of the appearance scale of the SCAR-Q at 3 months post-operation was 74.2 ± 8.8.

Conclusions

The novel endoscopy technique, which was first reported to perform lymph node surgery, N/SSM, and LDMF harvesting in an operation for breast cancer patients through a single axillary incision, is associated with a shorter surgery time, lower complication rates, and better patient-reported outcomes.

Breast Cancer Recurrence after Smooth vs. Textured Implant-Based Breast Reconstruction: A Matched Cohort Study

BACKGROUND

An increasing number of reports on breast implant-associated anaplastic large cell lymphoma have recently raised concerns about the potential influence of breast implants on carcinogenicity, particularly implants with a textured surface. We compared the recurrence outcomes between smooth and textured implant reconstructions for breast cancer.

METHODS

All patients who underwent immediate direct-to-implant (DTI)-based breast reconstruction for primary breast cancer between January 2010 and December 2016 were reviewed. A total of 590 patients were included. After propensity score 1:2 matching, 138 patients were included in the smooth implant group and 276 patients in the textured implant group. Locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), and distant metastasis-free survival (DMFS) rates were compared between the groups.

RESULTS

After matching, the median follow-up periods were 62 months and 66 months for the smooth and textured groups, respectively. We observed no significant differences between the smooth and textured implant groups in terms of locoregional recurrence (10.9% vs. 11.6%; P = 0.827), distant metastasis (3.6% vs. 4.0%; P = 0.547), or first recurrence (12.3% vs. 13.4%; P = 0.757) rates. No significant differences were observed between the groups in five-year LRRFS (89.5% vs. 89.4%; P = 0.840), DFS (87.7% vs. 88.1%; P = 0.794), or DMFS (98.8% vs. 96.8%; P = 0.741) rates.

CONCLUSIONS

No significant differences were observed between the smooth and textured implant groups in this matched cohort analysis of recurrence outcomes in patients with primary breast cancer who underwent immediate DTI reconstruction. Further larger-scale investigations are necessary to validate our results.

Genomic Analysis of Thrombophilia Variants in the General Population for the Creation of an Effective Preoperative Screening Tool

BACKGROUND

 The loss of a free flap in reconstructive microsurgery is a devastating complication in both the intraoperative and postoperative setting. Previous research has identified a variety of genetic polymorphisms that induce a hypercoagulable state and predispose patients to clot formation and subsequent free flap loss. We aim to review the risks of performing microsurgery on patients who are genetically predisposed to hypercoagulability, as well as identify options, for preoperative screening of inherited thrombophilia.

METHODS

 A thorough literature review was conducted with an online database. A total of 30 studies were reviewed to identify genetic polymorphisms that cause inherited thrombophilia. Through manual review of the literature, a table was created that included thrombotic risk factors and their associated genetic polymorphisms. If the information was available, prevalence for each thrombotic risk was also reported.

RESULTS

 Overall, 18 thrombotic risk factors that contribute to hereditary thrombophilia were identified and linked with specific genes and/or genetic polymorphisms. In studies that did not look at particular ethnic groups, 13 unique thrombotic risk factors were identified. In studies that examined specific ethnic groups exclusively, 12 thrombotic risk factors were identified and related to their respective gene or group of genes. Five of the 18 thrombotic risk factors identified were associated with increased risks of both venous and arterial thrombosis. The remainder of the thrombotic risk factors was associated with increased risk of venous thrombosis exclusively.

CONCLUSION

 The use of genetic screening tests for hereditary thrombophilia in the preoperative setting can serve as an effective preventative measure against postoperative thrombosis. Further exploration of thrombotic risk factors and their related genetic polymorphisms are important steps in reducing postoperative free flap loss.

Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction

BACKGROUND

Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction.

STUDY DESIGN

Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively.

RESULTS

Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications.

CONCLUSION

Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

Invited Discussion on: The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction

One in eight women will have a lifetime diagnosis of confirmed breast cancer, and one in three of these women will undergo a mastectomy. About half of women undergoing mastectomies will opt for some type of breast reconstruction. Breast cancer itself and breast reconstruction bring physical changes that are accompanied by psychological changes of varying degrees. The decision process about cancer treatment and whether or not to perform breast reconstruction brings suffering. In the case of choosing to perform the reconstruction, deciding when to perform it and which surgical technique to choose from among several available is quite complex, and may result in regret. The author provides a brief literature review on this subject and comments on the work carried out by Cai and Momeni, comparing data and results.Level of Evidence V 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.

TGF-β1 and CD68 immunoexpression in capsules formed by textured implants with and without mesh coverage: a study on female rats

PURPOSE

To evaluate fibrosis formation and number of macrophages in capsules formed around textured implants without and with mesh coverage.

METHODS

Fibrosis was analyzed through transforming growth factor-beta 1 (TGF-β1) immunomarker expression and the number of macrophages through CD68 percentage of cells in magnified field. Sixty female Wistar rats were distributed into two groups of 30 rats (unmeshed and meshed). Each group was then subdivided into two subgroups for postoperative evaluation after 30 and 90 days. The p value was adjusted by Bonferroni lower than 0.012.

RESULTS

No difference was observed in fibrosis between meshed and unmeshed groups (30 days p = 0.436; 90 days p = 0.079) and from 30 to 90 days in the unmeshed group (p = 0.426). The meshed group showed higher fibrosis on the 90th day (p = 0.001). The number of macrophages was similar between groups without and with mesh coverage (30 days p = 0.218; 90 days p = 0.044), and similar between subgroups 30 and 90 days (unmeshed p = 0.085; meshed p = 0.059).

CONCLUSIONS

In the meshed group, fibrosis formation was higher at 90 days and the mesh-covered implants produced capsules similar to microtextured ones when analyzing macrophages. Due to these characteristics, mesh coating did not seem to significantly affect the local fibrosis formation.

Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery

BACKGROUND

Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS.

MATERIALS AND METHODS

Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss.

RESULTS

956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567).

CONCLUSION

In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany-A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions

While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.