Daily serum collection after acellular dermal matrix-assisted breast reconstruction

Impact of Tissue Expander Surface Texture on Two-Stage Breast Reconstruction Outcomes: A Combined Analysis

BACKGROUND

With ongoing investigations of the impact of device texturing on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), studies have begun comparing complication profiles of tissue expanders. However, there is a paucity of timing and severity data of complications. The aim of this study was to provide a comparative survival analysis of postoperative complications between smooth (STEs) and textured tissue expanders (TTEs) in breast reconstruction.

METHODS

A single-institution experience with tissue expander breast reconstruction was reviewed for complications up to 1 year after second-stage reconstruction from 2014 to 2020. Demographics, comorbidities, operation-related variables, and complications were evaluated. Kaplan-Meier curves, Cox proportional hazard models, and a consensus-based ordinal logistic regression model were used to compare complication profiles.

RESULTS

Of 919 total patients, 600 (65.3%) received TTEs and 319 (34.7%) received STEs. There was increased risk of infection ( P < 0.0001), seroma ( P = 0.046), expander malposition ( P < 0.0001), and wound dehiscence ( P = 0.019) in STEs compared with TTEs. However, there was also a decreased risk of capsular contracture ( P = 0.005) in STEs compared with TTEs. Failure of breast reconstruction ( P < 0.001) and wound dehiscence ( P = 0.018) occurred significantly earlier in STEs compared with TTEs. Predictors for significantly higher severity complications included the following: smooth tissue expander use ( P = 0.007), shorter time to complication ( P < 0.0001), higher body mass index ( P = 0.005), smoking history ( P = 0.025), and nipple-sparing mastectomy ( P = 0.012).

CONCLUSIONS

Differences in the timing and severity of complications contribute to the safety profiles of tissue expanders. STEs are associated with increased odds of higher severity and earlier complications. Therefore, tissue expander selection may depend on underlying risk factors and severity predictors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Review: Implant-Based Breast Reconstruction After Mastectomy for Breast Cancer: A Meta-analysis of Randomized Controlled Trials and Prospective Studies Comparing Use of Acellular Dermal Matrix (ADM) Versus Without ADM

BACKGROUND

Breast cancer is the world's most prevalent cancer, and many breast cancer patients undergo mastectomy as the choice of treatment, often with post-mastectomy breast reconstruction. Acellular dermal matrix (ADM) use has become a method to improve outcomes of reconstruction for these patients. We aimed to compare postoperative complications and patient-reported outcomes, which are still poorly characterized, between groups utilizing acellular dermal matrix during reconstruction and those without.

MATERIALS AND METHODS

We searched electronic databases from inception to 16 June 2022 for randomized controlled trials and prospective cohort studies comparing the outcomes of patients who have and have not received acellular dermal matrix in implant-based breast reconstruction. The results were quantitatively combined and analyzed using random-effects models.

RESULTS

A total of nine studies were included, representing 3161 breasts. There was no significant difference in postoperative outcomes, such as seroma formation (p = 0.51), hematomas (p = 0.20), infections (p = 0.21), wound dehiscence (p = 0.09), reoperations (p = 0.70), implant loss (p = 0.27), or skin necrosis (p = 0.21). Only two of the studies included evaluated patient-reported outcomes between the use and non-use of ADM in implant-based breast reconstruction using BREAST-Q questionnaire, as well as self-reported pain. There was no reported significant difference in BREAST-Q or pain scores.

CONCLUSIONS

This meta-analysis shows comparable short- and long-term outcomes between ADM and non-ADM breast reconstruction, suggesting that the use of ADM may not be necessary in all cases given their additional cost. However, there is a paucity of data for patient-reported outcomes, and further research is required to determine whether ADM use affects patient-reported outcomes.

Pre-pectoral breast reconstruction with tissue expander entirely covered by acellular dermal matrix: feasibility, safety and histological features resulting from the first 64 procedures

Background

Reconstructive options that can be used following conservative mastectomy, skin-, nipple-sparing and skin-reducing mastectomies, allow a remarkable variety of safe methods to restore the natural shape and aesthetics of the breast mound. In case of two-stage breast reconstruction, tissue expanders (TEs) are usually placed in a subpectoral position. The purpose of this retrospective cohort study is to evaluate the feasibility and safety of two-step reconstruction with TE in pre-pectoral position covered by acellular dermal matrix (ADM).

Methods

Between March 2021 and May 2023, at the Azienda Ospedaliero Universitaria Careggi, University of Florence, 55 patients with BRCA 1/2 mutations or early breast cancer underwent conservative mastectomy with immediate pre-pectoral reconstruction using TE covered with ADM, followed by a second surgery with replacement of the expander with definitive prosthesis. Demographic, oncological, and histological data along with surgical complications were recorded.

Results

A total of 64 conservative mastectomies were performed. In 2 patients (3.1%) complications were found that required reintervention and, in both cases, the TE had to be removed. Two patients developed hematoma and one patient developed seroma. Two patients showed wound dehiscence, both healed after conservative treatment and without implant exposure. No case of necrosis of the skin or nipple-areola complex has been observed, neither of capsular contracture. Capsule formed around TE was populated with cells and blood vessels and showed a thin area of synovial metaplasia.

Conclusions

In selected cases it may be more cautious to perform a two-stage breast reconstruction after radical breast surgery by means of TEs. The placement of TEs in pre-pectoral position combines the excellent aesthetic and functional results of the pre-pectoral philosophy with a quite safer and more prudent two-step approach. Our experience reports optimistic results: the ADM covering the TE is seen successfully integrating during tissue expansion and becoming a vascularised new self-tissue. Complications rates are low and such ADM-assisted two-stage pre-pectoral reconstructive technique is a safe, practical, and reproducible method.

A Two-Year Retrospective Analysis of the Clinical Outcomes of Immediate Submuscular Breast Reconstructions With Native® Acellular Dermal Matrix

BACKGROUND

Implant-based submuscular breast reconstruction (SBR) can be performed with the aid of acellular dermal matrices (ADM) for implant coverage on their inferolateral pole, aiming at providing a biological interface for hiding the implant and therefore reducing the risk of complications. The purpose of this study is to assess the long-term post-operative outcomes obtained using the SBR-specific Native® ADM (DECO med s.r.l., Marcon, Venice, Italy).

METHODS

All cases of Native®-assisted immediate SBR performed at our institution between October 2016 and March 2020 were retrospectively analysed. Demographic and surgical data were collected, and post-operative outcomes, including minor and major complications, were evaluated. Particular attention was paid to complications emerging before and after patient discharge. Dependence analyses were performed to uncover statistically significant relationships between risk factors and reconstructive outcomes.

RESULTS

Data on 100 patients were collected, for a total of 128 breasts. The mean age of the cohort was 49.5 years, the mean BMI was 23.4 kg/m2, and the mean follow-up was 24 months. Out of this, 14.1% of patients received pre-operative radiotherapy, while 16.4% underwent post-mastectomy radiotherapy. Breasts appeared to develop short-term minor complications more likely during hospitalisation (11.7% vs. 7.8%), while short-term major complications occurred more often after discharge (7.8% vs. 15.6%). The most frequent long-term complications were capsular contracture and contour defects (both 9.4%). Risk factors that showed a statistically significant relationship with complications were pre- and post-mastectomy radiotherapy and post-operative chemotherapy.

CONCLUSIONS

The retrospective analysis showed results in line with clinical outcomes reported in the literature for the same reconstructive technique. The use of Native® ADM in SBR is safe and effective in the long term.

Braxon®-assisted prepectoral breast reconstruction: A decade later

We are sitting on the cusp of the bioengineered breast era, in which implant-based breast reconstruction is seeing a growing trend and biotechnology research progressively empowers clinical practice. As never before, the choice of biomaterials has acquired great importance for achieving reconstructive outcomes, and the increase in the use of acellular dermal matrices (ADMs) in the field of senology tells us a story of profound upheaval and progress. With the advent of prepectoral breast reconstruction (PPBR), plenty of devices have been proposed to wrap the silicone prosthesis, either completely or partially. However, this has caused a great deal of confusion and dissent with regard to the adoption of feasible reconstructive strategies as well as the original scientific rationale underlying the prepectoral approach. Braxon^® is the very first device that made prepectoral implant positioning possible, wrapping around the prosthesis and exerting the proven ADM regenerative potential at the implant–tissue interface, taking advantage of the body's physiological healing mechanisms. To date, the Braxon^® method is among the most studied and practiced worldwide, and more than 50 publications confirm the superior performance of the device in the most varied clinical scenarios. However, a comprehensive record of the working of this pioneering device is still missing. Therefore, our aim with this review is to lay a structured knowledge of surgery with BRAXON^® and to provide a decision-making tool in the field of PPBR through a complete understanding on the very first device for prepectoral, one decade after its introduction.

Muscle-Sparing Skin-Reducing Breast Reconstruction with Pre-Pectoral Implants in Breast Cancer Patients: Long-Term Assessment of Patients' Satisfaction and Quality of Life

INTRODUCTION

Breast cancer is the most frequently diagnosed tumor in women; globally, it accounts 23% of all cancer deaths. Breast reconstruction after oncologic surgery has become crucial to enhance patients' quality of life and alleviate the psychological distress related to the disease. The aim of this study was to assess quality of life and esthetic satisfaction of breast cancer patients undergoing muscle-sparing skin-reducing breast reconstruction (MS-SR) with pre-pectoral implants.

METHODS

Sixty-three patients who met definite oncological and reconstructive criteria were enrolled in the study. Specific questionnaires (EORTC QLQ-C30, QLQ-BR23) were administered preoperatively, 1, and 12 months after MS-SR breast reconstruction to evaluate patients' QoL. Satisfaction with procedure and related Quality of Life were assessed through BREAST-Q questionnaire preoperatively and 12 months after surgery.

RESULTS

Sixty-three breast cancer patients underwent MS-SR. Seventy-eight procedures were carried out; in 15 patients a bilateral reconstruction was performed. One month after surgery, both EORTC QLQ-C30 and QLQ-BR23 average scores demonstrated a slight drop since preoperative values, but a significant improvement in QoL was documented 12 months after BR (p < 0.05). BREAST-Q test showed significant psychophysical and esthetic satisfaction 12 months postoperatively.

CONCLUSIONS

Muscle-sparing skin-reducing breast reconstruction is an established and reliable technique. EORTC QLQ-C30, QLQ-BR23 and BREAST-Q scores showed an improvement of patients' QoL and esthetic satisfaction. Reduction of pain and other surgery-related symptoms are cornerstones of patient well-being. Both physicians and patients should build a thorough awareness of the silver lining of muscle-sparing skin-reducing breast reconstruction based on the high safety profile and highly satisfactory patient-reported results.

Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes

BACKGROUND

The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking.

METHODS

Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors.

RESULTS

Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis.

CONCLUSIONS

Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparative study of patient outcomes between direct to implant and two-stage implant-based breast reconstruction after mastectomy

BACKGROUND

Breast reconstruction plays a central role in the outcome management of patients with breast cancer, particularly in terms of quality of life (QoL), which must be weighed carefully when considering the available surgical options. In the context of implant-based breast reconstruction, immediate replacement with prosthesis (direct-to-implant (DTI)) and acellular dermal matrix (ADM) is gaining popularity, at the expense of the traditional two-stage implant-based breast reconstruction with tissue expander (TE), and the literature suggests that patients tend to prefer interventions with "immediate" therapeutic efficacy and aesthetic satisfaction that obviate the need for further invasive surgery. We investigated this hypothesis by administering the BREAST-Q™ questionnaire to two groups of patients who had undergone the respective procedures.

METHODS

We performed a cross-sectional observational study of 192 consecutive mastectomy patients who received implant-based reconstruction, comparing health-related quality of life (HR-QoL), patient-related outcomes (PROs) and satisfaction in patients who had undergone immediate dual plane DTI with ADM (96) versus the two-stage submuscular approach (96). We also counted the number of surgeries required in each group to achieve a definitive outcome.

FINDINGS

Our study revealed no major differences in terms of QoL scores, with the two approaches being largely comparable. However, single-stage reconstruction seems to offer the additional advantages of better satisfaction with the care received, sparing the patient temporary body image dissatisfaction and reducing the number of surgeries required, thereby lessening the burden on the patient, the healthcare system and society as a whole.

Quality of Life and Early Functional Evaluation in Direct-to-Implant Breast Reconstruction After Mastectomy: A Comparative Study Between Prepectoral Versus Dual-Plane Reconstruction

BACKGROUND

In conservative mastectomies, in which the native skin envelope is preserved, positioning an implant in the submuscular plane commonly leads to functional consequences like upper limb movement impairment and animation phenomena. In recent years, however, a new conservative prepectoral breast reconstruction technique has been proposed, with demonstrated surgical safety and aesthetic effectiveness. The aim of our study was to explore and compare the functional and aesthetic outcomes of the prepectoral/acellular dermal matrix (ADM)-wrapped implant procedure versus subpectoral/ADM-assisted reconstruction.

PATIENTS AND METHODS

A retrospective nonrandomized comparative study of 94 patients (121 breasts) undergoing direct-to-implant breast reconstruction after skin-/nipple-sparing and skin reduction was conducted from February 2013 to October 2017. Fifty-five patients (group A) received subpectoral ADM-assisted reconstruction with dual-plane implant positioning, and 39 patients (group B) received prepectoral partially or totally ADM-wrapped implant reconstruction. Patients were allocated to either group A or B depending on the mastectomy flap thickness and vitality, as assessed clinically during the operation. Details of rehabilitation program, postoperative pain at 72 hours, postoperative analgesic therapies, demographic data, and complications were recorded. Upper limb function was assessed before and 1 month after surgery by a physiatrist according to a precise protocol. Patients were asked to fill in the BREAST-Q reconstruction questionnaire after surgery to evaluate outcomes.

RESULTS

Differences in upper limb function between groups, namely flexion (P = .03), abduction (P = .003), internal rotation (P = .02), and external rotation (P = .05), were statistically significant. Although most patients required postoperative rehabilitation, the individual rehabilitation intervention frequency was greater in the subpectoral group (91% in group A vs 74% in group B). There was also a significant difference in postoperative pain (within 72 hours), with less pain perceived in the prepectoral group (P = .01). Furthermore, prepectoral patients reported slightly better postoperative quality of life than subpectoral patients, particularly in the domains of sexual well-being (P = .005) and satisfaction with breast (P = .002).

CONCLUSION

In our case series, prepectoral implant positioning with partial or total ADM coverage led to less impairment of upper limb function in terms of flexion, abduction, and internal and external rotation, and also reduce the need for rehabilitation. Furthermore, as a result of the less invasive procedure, prepectoral patients had less immediate postoperative pain and were more satisfied with breast appearance.

Drain secretion and seroma formation after immediate breast reconstruction with a biological and a synthetic mesh, respectively: A randomized controlled study

The aim of this study was to compare seroma production in breast reconstruction with a biological mesh with that of a synthetic mesh, in the same patient. The patients were randomized to biological mesh in one breast and synthetical in the other. Twenty-four breasts were included. The total drain production and the daily drain production were similar in the two groups. After drain removal, there were more seroma aspirations in the biological group. During the exchange to a permanent implant, there was significantly more seroma in the biological group. Seroma formation is different in synthetic and biological meshes.

Drainage Collection After Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty Using Cold or Electrosurgical Separation of Interpectoral Space

Background

Endoscopic transaxillary augmentation mammaplasty breast augmentation offers several advantages over other augmentation methods. Nonetheless, this procedure is fraught with some problems, including greater surgical trauma due to the longer separation area. We hypothesized that cold separation of the interpectoral space could reduce surgical injury in comparison to the electrosurgical method. This study aimed to compare the outcomes of endoscopic-assisted transaxillary augmentation mammaplasty using cold separation versus electrosurgical separation of the interpectoral space.

Methods

In this prospective clinical trial, cold and electrosurgical separation of the interpectoral space were achieved using a separation shovel and monopolar electrotome, respectively. A total of 20 patients who visited our department in Beijing, China, for primary breast augmentation surgeries from October 1, 2017, and May 31, 2018, were included. The primary outcome was total postoperative drainage volume. The secondary outcomes were operative time, daily drainage volume, daily pain as assessed using the visual analogue scale (VAS), and reoperation rate. Quantitative data were compared using independent-samples t test. Chi-square test was used to compare 2 classified indexes.

Results

The total drainage volume was significantly lower in the cold separation group than in the electrosurgical separation group (170.45 ± 75.40 mL vs 281.05 ± 148.43 mL; P = .005). The VAS score on the first postoperative day was significantly lower in the cold separation group than in the electrosurgical separation group (6.45 ± 1.93 vs 7.55 ± 1.43; P = .048). Two (20%) reoperations owing to postoperative pain or implant stiffness were performed in the electrosurgical separation group.

Conclusions

Cold separation is more conducive to reducing drainage, relieving postoperative pain, and causing less damage than the electrosurgical method in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty.

Predictive Factors for Drainage Volume after Expander-based Breast Reconstruction

BACKGROUND

Closed suction drains are widely used in breast reconstruction, and the drains are removed based on a volume criterion. However, to the best of our knowledge, there has been no study analyzing predictive factors for drainage volume after breast reconstruction.

METHODS

Data of daily drainage in cases with expander-based breast reconstruction between February 2013 and March 2015 (131 patients and 134 expanders) were retrospectively analyzed. Patient factors and operative factors were examined for their influences on total drainage using univariate and multivariate analyses.

RESULTS

The total drainage was 557.3 ± 359.7 mL. A strong correlation was observed between total drainage and duration of drains (correlation coefficient, 0.908). Operative factors, such as mastectomy type, expander type, operative time, and blood loss, did not affect the total drainage. Patients with axillary lymph node dissection showed a higher total volume of drainage (P < 0.001). The weight of the resected specimen, body weight, and breast volume calculated preoperatively showed a strong correlation with total drainage (correlation coefficients, 0.454, 0.388, and 0.345, respectively). In multiple regression analysis with preoperative data, age (P = 0.008), body weight (P = 0.018), and scheduled axillary dissection (P < 0.001) were significant predictive factors for total drainage. Among postoperative data, age (P = 0.003), axillary dissection (P = 0.032), and weight of resected specimen (P = 0.013) were significant predictors.

CONCLUSIONS

Based on preoperative and/or postoperative information, plastic surgeons can predict the total drainage and duration of drains after expander-based breast reconstruction. Age, breast mass, and axillary lymph node dissection are important factors for this prediction.