The influence of a previous implant-based breast reconstruction on postoperative sensation of the deep inferior epigastric artery perforator flap

BACKGROUND

Implants and DIEP flaps have different outcomes regarding postoperative breast sensation. When compared to the preoperative healthy breast, implant-based breast reconstruction (IBBR) negatively influences postoperative breast sensation. However, it is currently unknown whether a prior IBBR also influences postoperative sensation of a replacing DIEP flap. The goal of this cohort study is to evaluate the influence of an IBBR on the postoperative sensation of a replacing DIEP flap.

METHODS

Women were included if they received a DIEP flap reconstruction after mastectomy, with or without prior tissue expander (TE) and/or definitive breast implant. Sensation was measured at four intervals in 9 areas of the breast with Semmes-Weinstein monofilaments: T0 (preoperative, implant/no reconstruction), T1 (2-7 months postoperative, DIEP), T2 (± 12 months postoperative, DIEP), Tmax (maximum follow-up, DIEP). Linear mixed-effects models were used to investigate the relationship between an implant/TE prior to the DIEP flap and recovery of breast sensation.

RESULTS

142 women comprising 206 breasts were included. 48 (23.3%) breasts did, and 158 (76.7%) breasts did not have a TE/IBBR prior to their DIEP. No statistically significant or clinically relevant relationships were found between a prior implant/TE and recovery of DIEP flap breast sensation for the flap skin, native skin, or total breast skin at T1, T2, or Tmax. There were also no relationships found after adjustment for the confounders radiation therapy, BMI, diabetes, age, flap weight, follow-up, and nerve coaptation.

CONCLUSIONS

An implant/TE prior to a DIEP flap does not influence the recovery of postoperative breast sensation of the DIEP flap.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis

BACKGROUND

A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point.

METHODS

We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications.

RESULTS

A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results.

CONCLUSION

At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

The impact of neoadjuvant chemotherapy on surgical outcomes following autologous and implant-based immediate breast reconstruction: A systematic review and meta-analysis

BACKGROUND

The impact of neoadjuvant chemotherapy (NACT) on the complication rate after implant-based and autologous breast reconstruction remains unclear. The aim of this study was to systematically review and perform a meta-analysis of previously published studies on immediate breast reconstruction (IBR) in breast cancer patients treated with NACT compared with controls.

METHODS

PubMed and EMBASE were searched to identify studies assessing the impact of NACT on major and minor complications after IBR. The primary effect measures were relative risk (RR), 95% confidence interval (95% CI), and p-value.

RESULTS

Eight studies comprising 51,731 patients were included in the meta-analysis. Of these, 5161 patients received NACT and 46,570 patients did not receive NACT. In regard to major complications, NACT did not statistically significant increase the rate of reconstructive failure (RR = 1.35, 95% CI = 0.96-1.91, p = 0.09), the rate of mastectomy skin-flap necrosis (RR = 1.39, 95% CI = 0.61-3.17, p = 0.44), or the rate of reoperation (RR = 1.09, 95% CI = 0.87-1.37, p = 0.45). Regarding minor complications, NACT did not significantly increase the rate of wound complications (RR = 1.05, 95% CI = 0.87-1.28, p = 0.62). In a subgroup analysis of implant-based breast reconstruction following NACT, single-stage direct-to-implant (DTI) had a significantly lower implant failure rate compared with two-staged tissue expander/implant (TE/I) (RR = 0.43, 95% CI = 0.26-0.71, p = 0.0011).

CONCLUSION

NACT did not increase the major or minor complication rate after IBR with either autologous tissue or implants. Thus, NACT and IBR should be considered safe procedures. The review of studies describing patients undergoing implant-based breast reconstruction following NACT could indicate that single-stage DTI was a safer procedure than two-staged TE/I. However, the association requires further evaluation.

ADM-Assisted Direct-to-Implant Prepectoral Breast Reconstruction in Postmastectomy Radiation Therapy Setting: Long-Term Results

BACKGROUND

Postmastectomy radiotherapy (PMRT) on immediate breast reconstruction historically involved a marked increase in complication rate (up to 50%). Prepectoral breast reconstruction (PPBR) has shown promising early postoperative results. This study aims to evaluate PPBR long-term results in PMRT setting.

MATERIALS AND METHODS

This is a retrospective monocentric analysis of 485 PPBR (439 patients) undergoing Acellular-Dermal-Matrix assisted direct-to-implant reconstruction (46 bilateral procedures) between January 2015 and December 2020 (mean FU:35.6 months). Group 1 comprised 401 PPBR not submitted to PMRT, and 84 reconstructions receiving PMRT in Group 2. Patients' characteristics, postoperative complication and revisional surgery rate were examined. PMRT characteristics and subcutaneous tissue thickness, measured in Group 2 by CT scan, were also evaluated.

RESULTS

Long-term complication rate was 11.2% in Group 1 vs. 21.4% in Group 2 (P-value = .019). Capsular contracture represented the only complication associated to a statistically significant difference between the 2 groups (P-value < .001). In Group 2, only 4.8% implant loss and 8.3% severe capsular contracture rate was found. In patients who underwent PMRT, 38.9% of complications settled with no consequences, and only 4.8% of patients needed revisional surgery in the long-term FU. According to multivariate analysis, drug intake and PMRT were significantly associated with postoperative complications. In Group 2, a thinner subcutaneous tissue was linked to a higher complication risk.

CONCLUSION

In our series, patients treated with PPBR who underwent PMRT, presented a low complication rate and minimal need for revisional surgery in the long-term follow-up, suggesting that this technique is feasible and safe also in PMRT context.

The Impact of Adjuvant Radiotherapy on Immediate Prepectoral Implant-Based Breast Reconstruction

BACKGROUND

Immediate prepectoral implant-based breast reconstruction (IBBR) rates have increased in recent years owing to improved cosmetic and psychological benefits. However, there is a lack of studies regarding complications rates following adjuvant radiotherapy (RT) among patients undergoing immediate prepectoral IBBR.

METHODS

We conducted a retrospective monocentric analysis of a cohort of consecutively treated patients who underwent NSM following immediate prepectoral IBBR at our institution between March 2017 and November 2021. Patient demographics, quality of life, complication rates, and oncological safety were evaluated in the RT and non-RT groups. Data analysis was performed using IBM SPSS Version 24 (IMB Corp., Armonk, NY, USA).

RESULTS

A total of 98 patients were examined: 70 were assigned to have prepectoral IBBR without RT and 28 to the group who had prepectoral IBBR with RT. There was a statistically significant difference in overall capsular contracture rate between the RT and non-RT group (18% vs. 4.3%, p=0.04). The total implant loss in the cohort was 4% (10.7% vs. 1.4%, p=0.05). We obtained a high percentages of all BREAST-Q categories in both groups; however, satisfaction with the breast and sexual well-being was higher in the non-RT group. The three-year overall survivals were 97.4% in the RT group and 98.5% in the non-RT group.

CONCLUSION

Our findings showed that patients in the RT group had a higher rate of capsular contracture and implant loss than those in the non-RT group. However, complication rates were within acceptable range and with accurate preoperative information patients have more benefits from immediate reconstruction showing excellent overall quality of life irrespectively of radiation.

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 .

Literature review and guide for optimal position in implant-based breast reconstruction

Background and Objective

Identification of ideal candidates for prepectoral versus retropectoral implant-based breast reconstruction relies on careful preoperative risk assessment and intraoperative flap evaluation. Few guidelines exist to guide the surgeon's decision-making process when evaluating the preferred plane for implant placement.

Methods

A literature review was performed to develop clinical decision-making algorithms for direct-to-implant (DTI) reconstruction with acellular dermal matrix (ADM) for patients undergoing prophylactic or therapeutic nipple-sparing mastectomy (NSM) based on patient characteristics, surgical techniques, and outcomes.

Key Content and Findings

Prepectoral reconstruction is most suitable for patients with small breasts or macromastia with desire for breast reduction, low-grade ptosis, smaller implant sizes, those undergoing PMRT, and for those who aim to mitigate animation deformity and capsular contracture. Retropectoral reconstruction may be recommended for patients with larger breasts with no desire for size change requiring additional prosthesis support, and in patients who aim to reduce likelihood of rippling and need for subsequent fat grafting procedures to address contour abnormalities.

Conclusions

Careful preoperative and intraoperative assessment of reconstruction options for patients undergoing implant-based breast reconstruction is necessary to mitigate complications and produce superior aesthetic outcomes. Decision algorithms may be used to determine ideal surgical techniques based on patient factors, like radiation history and planning, breast size and ptosis, and patient preferences.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE III

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

Comparison of the Characteristics of Three Acellular Dermal Matrices Subjected to Distinct Processing Methods Using Five Types of Histochemical Staining

BACKGROUND

Acellular dermal matrix (ADM) is treated using various devitalization and aseptic processing methods. The processing effects on ADM were evaluated by histochemical tests.

METHODS

From January 2014 to December 2016, 18 patients [average age, 43.0 (range, 30-54) years] who underwent breast reconstruction with an ADM and tissue expander were prospectively enrolled. During the permanent implant replacement, a biopsy of the ADM was performed. We used three different human-derived products, namely, Alloderm®, Allomend®, and Megaderm®. Hematoxylin and eosin, CD68, CD3, CD31, and smooth muscle actin were used to evaluate the collagen structure, inflammation, angiogenesis, and myofibroblast infiltration. Each ADM was semi-quantitatively analyzed.

RESULTS

Significant differences in collagen degradation, acute inflammation, and myofibroblast infiltration were observed among the ADMs. Collagen degeneration (p<0.001) and myofibroblast infiltration (smooth muscle actin-positive, p=0.018; CD31-negative, p=0.765) were the most severe in Megaderm®. Acute inflammation, represented by CD68, was most severe in Alloderm® (p=0.024). Both radiation and freeze-drying treatment physically damaged the collagen structure. Collagen degeneration was most severe in Megaderm®, followed by Allomend® and Alloderm®. Since Alloderm® is treated using chemicals, an assessment of the chemical irritation is warranted.

CONCLUSIONS

The biopsy results were inconclusive. Therefore, to better interpret processing, more large-scale, serial, histochemical studies of each ADM are needed.

LEVEL OF EVIDENCE IV

This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

The Partner Perspective on Autologous and Implant-Based Breast Reconstruction

INTRODUCTION

Partner involvement in the decision-making process concerning breast reconstruction (BR) after a breast cancer diagnosis may be very supportive for the patient. So far, no study evaluates partner satisfaction with the outcome after BR and the relationship to patient satisfaction. The aim of this study was to assess and compare partner satisfaction of BR with autologous tissue (ABR) and prosthetic implants (IBR), respectively, and compare it to patient-reported outcomes.

PATIENTS AND METHODS

All patients undergoing ABR and IBR between January 2014 and December 2020 were asked to participate with their partners. Patient and partner satisfaction with breast reconstruction, overall outcome as well as patient's perceived and self-reported psychosocial well-being were evaluated using the Breast-Q and a modified partner questionnaire, respectively.

RESULTS

Fifty-three couples participated (IBR: n=30, ABR: n = 23). Patient and partner satisfaction with breast (r = 0.552), outcome (r = 0.465) as well as patient's perceived and self-report psychosocial well-being (r = 0.495) were highly correlated with partners scoring significantly higher (p<0.001). In terms of partner satisfaction, both reconstructive procedures achieved satisfactory results. ABR scored higher in terms of softness of breast and how natural the breast feels to touch whereas IBR was rated superior evaluating the breast size.

CONCLUSION

Both reconstructive procedures achieve satisfactory results in terms partner satisfaction whereas patient's psychosocial well-being was highly overestimated by their partners. Hence, partner inclusion in the regular psycho-oncological support might further sensitize them of the high psychological burden of a breast cancer diagnosis and therefore stabilize patients private support system.

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 .

[Renaissance of prepectoral implant-based breast reconstruction: theoretical basis and research status]

Objective

To overview the theoretical basis and research status of prepectoral implant-based breast reconstruction.

Methods

The domestic and foreign researches on the application of prepectoral implant-based breast reconstruction in breast reconstruction were retrospectively analyzed. The theoretical basis, clinical advantages, and limitations of this technique were summarized and the future development trend in this field was discussed.

Results

The recent advances in breast cancer oncology, the development of materials and the concept of oncology reconstruction have provided a theoretical basis for prepectoral implant-based breast reconstruction. The selection of patients and the experience of surgeons are crucial for postoperative outcomes. Ideal thickness and blood flow of flaps are the most important considerations for the selection of prepectoral implant-based breast reconstruction. However, its long-term reconstruction outcomes and clinical benefits and risks in Asian populations still need to be confirmed by more studies.

Conclusion

Prepectoral implant-based breast reconstruction has a broad application prospect in breast reconstruction following mastectomy. However, the evidence is limited at present. Randomized study with long-term follow-up is urgently in need to provide sufficient evidence to evaluate the safety and reliability of prepectoral implant-based breast reconstruction.

Use of PEAK PlasmaBlade in implant-based breast reconstruction and radiotherapy: new strategy to reduce complications

BACKGROUND

Implant-based breast reconstruction in the setting of radiotherapy often leads to higher complications rates (mainly capsular contracture and wound dehiscence) and poor cosmetic outcomes. We hypothesized that the combination of pulsed-electron avalanche knife (PEAK) PlasmaBlade (a pulsed radiofrequency electrosurgery) and acellular dermal matrix Veritas® in postmastectomy radiotherapy implant-based breast reconstruction could result in lower complications rate, better reconstructive results, and patient satisfaction.

METHODS

A prospective observational study focused on the use of PEAK PlasmaBlade in implant-based breast reconstruction and radiotherapy was carried out in the Plastic Reconstructive Surgery Unit at Fondazione IRCCS Istituto Nazionale Tumori Milano between December 2017 and 2019 (2017-2018: enrollment; 2018-2019: follow-up). Patient demographics were queried and complication rates and patient and surgeon satisfaction were assessed.

RESULTS

A total of 88 patients were enrolled; 2 patients received bilateral reconstruction, leading to a total of 90 procedures. Sixty-two women received contralateral symmetrization. Seroma was the most frequent minor complication (8.8%); implant exposure was the most recorded among major complications (5.5%). Preoperative lipofilling was the most substantial protective factor for preventing complications (p < 0.001). A significant association between capsular thermal damage thickness and the type of electrosurgery used (traditional electrosurgery vs PEAK PlasmaBlade) was observed, with lower values with PEAK PlasmaBlade (p < 0.0001).

CONCLUSIONS

Our protocol results in low rates of surgical complications and a high level of patient and surgeon satisfaction although longer follow-up is needed.

Capsular inflammation after immediate breast reconstruction - Gene expression patterns and inflammatory cell infiltration in irradiated and non-irradiated breasts

BACKGROUND

Capsular contracture following post-mastectomy radiotherapy (PMRT) is commonly seen in patients undergoing implant-based immediate breast reconstruction (IBR). Further understanding of the underlying biology is needed for the development of preventive or therapeutic strategies. Therefore, we conducted a comparative study of gene expression patterns in capsular tissue from breast cancer patients who had received versus those who had not received PMRT after implant-based IBR.

METHODS

Biopsies from irradiated and healthy non-irradiated capsular tissue were harvested during implant exchange following IBR. Biopsies from irradiated (n = 13) and non-irradiated (n = 12) capsules were compared using Affymetrix microarrays to identify the most differentially regulated genes. Further analysis using immunohistochemistry was performed in a subset of materials to compare the presence of T cells, B cells, and macrophages.

RESULTS

Enrichment testing using Gene Ontology (GO) analysis revealed that the 227 most differentially expressed genes were mainly involved in an inflammatory response. Twenty-one GO biological processes were identified [p < 0.05, false discovery rate (FDR) < 5%], several with B-cell-associated inflammation. Cell-type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT) analysis identified macrophages as the most common inflammatory cell type in both groups, further supported by immunostaining of CD68. Radiation remarkably increased B-cell infiltration in the capsular region of biopsies, as quantified by immunostaining of CD20 (p = 0.016).

CONCLUSIONS

Transcript analysis and immunohistochemistry revealed inflammatory responses in capsular biopsies regardless of radiotherapy. However, the radiation response specifically involved B-cell-associated inflammatory responses.

Nation-wide validation of a multicenter risk model for implant loss following implant-based breast reconstruction

INTRODUCTION

Implant loss following breast reconstruction is a devastating complication, which should be prevented as much as possible. This study aimed to validate a previously developed multicenter risk model for implant loss after implant-based breast reconstructions, using national data from the Dutch Breast Implant Registry (DBIR).

METHODS

The validation cohort consisted of patients who underwent a mastectomy followed by either a direct-to-implant (DTI) or two-stage breast reconstruction between September 2017 and January 2021 registered in the DBIR. Reconstructions with an autologous adjunctive and patients with missing data on the risk factors extracted from the multicenter risk model (obesity, smoking, nipple preserving procedure, DTI reconstruction) were excluded. The primary outcome was implant loss. The predicted probability of implant loss was calculated using beta regression coefficients extracted from the multicenter risk model and compared to the observed probability.

RESULTS

The validation cohort consisted of 3769 reconstructions and implant loss occurred after 307 reconstructions (8.1%). Although the observed implant loss rate increased when the risk factors accumulated, the predicted and observed probabilities of implant loss did not match. Of the four risk factors in the multicenter risk model, only obesity and smoking were significantly associated to implant loss.

CONCLUSION

The multicenter risk model could not be validated using nationwide data of the DBIR and is therefore not accurate in Dutch practice. In the future, the risk model should be improved by including other factors to provide a validated tool for the preoperative risk assessment of implant loss.

Postmastectomy Radiation Therapy in the Setting of Two-Stage Retropectoral Implant-Based Breast Reconstruction: Should It be Delivered Before or After Implant Exchange? A Retrospective Analysis on 183 Patients

INTRODUCTION

Postmastectomy radiation therapy (PMRT) has a primary role in the treatment of locally advanced breast cancer; however, the most appropriate timing of irradiation in immediate tissue expander breast reconstruction (ITEBR) still remains unknown.

METHODS

A retrospective review was performed on all women undergoing mastectomy and retropectoral ITEBR at Campus Bio-Medico University Hospital in Rome, Italy, between 2010 and 2019. The patients were categorized into three cohorts: patients undergoing PMRT with the tissue expander (TE) in situ, patients with PMRT delivered to the permanent implant (PI), patients who were not administered RT. Complications and failure rates were analysed and compared. Potential predictors of adverse outcomes were analysed.

RESULTS

Over 10 years, 183 patients underwent retropectoral ITEBR (55 PMRT-TE, 50 PMRT-PI, 78 no-PMRT). The three groups were well matched with respect to patient- and treatment-related factors (p > 0.05), with the exception of neoadjuvant chemotherapy and irradiation. The mean follow-up was, respectively, 4.58, 7 and 5.75 years. Radiotherapy either to the TE or to the PI was independently associated with failure and conversion to autologous procedures (p < 0.0001). Failure rate was significantly higher when TE was irradiated (p = 0.03). PMRT was associated with severe capsular contracture development (p < 0.00001), the odds being higher when irradiation was delivered after implant exchange (p = 0.04). Increased BMI was significantly associated with failure.

CONCLUSIONS

When PMRT is delivered to the TE, the risk of failure is higher (OR 2.77); when the PI is irradiated, reconstruction will more likely be affected by severe capsular contracture (OR 2.7). However, considering that the overall risk of severe capsular contracture correlated to PMRT is higher than failure, we believe that irradiation should be delivered to the TE. Performing a proper capsuloplasty at the time of implant exchange, indeed, allows to correct the deformities related to radiation-induced capsular contracture. Patients with unfavourable outcomes after TE placement and RT, instead, can be directly switched to autologous reconstruction.

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 .

Patient-reported outcome measurements in post-mastectomy implant-based breast reconstruction and radiotherapy: Analysis of BREAST-Q data

BACKGROUND

Breast reconstruction has become a standard of care in patients undergoing mastectomy, greatly improving their quality of life. An increasing number of patients-reported outcome measurements (PROMs) have been developed over the years to better analyze patients' subjective overall experience. BREAST-Q is the PROMs for breast surgery introduced in our practice to assess patients' experiences when undergoing implant-based breast reconstruction and radiotherapy along with the use of Peak Plasma Blade and acellular dermal matrix.

METHODS

The pre-operative version of the Reconstruction BREAST-Q was administered to all 88 patients enrolled between December 2017 and December 2018 in the Plastic Reconstructive Surgery Unit at Fondazione IRCCS Istituto Nazionale Tumori Milano through person-to-person interviews, while the post-operative version was administered to the 75 patients who completed a 12-month follow-up (four patients died during one-year follow-up and nine patients had major complications). The survey areas highlighted were: satisfaction with breast, psychosocial well-being, physical well-being and sexual well-being.

RESULTS

From BREAST-Q questions regarding Satisfaction With The Appearance Of The Breast and Psychosocial Well-Being outcomes showed significant improvement from pre-operative data, as well as with Satisfaction With Overall Care, with the exception of Physical Well-Being Chest.

CONCLUSIONS

BREAST-Q allows the assessment of patients' perception, not only for surgical results, but also for the overall experience with surgeons and medical staff.The women enrolled in our study reported an overall good patient satisfaction in most of the analyzed fields.

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

Aim

Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario.

Methods

A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology.

Results

The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR.

Conclusions

The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR

•

Autologous breast reconstruction is increasingly preferred over implants in the setting of radiation therapy.

•

Use of patient-reported outcomes is endorsed.

•

Shape and size of reconstructed breasts can hinder radiotherapy planning.

•

There is a need for randomised phase III trials.

Quality of life, pain of prepectoral and subpectoral implant-based breast reconstruction with a discussion on cost: A systematic review and meta-analysis

INTRODUCTION

Prepectoral implant-based breast reconstruction (PIBR) has regained popularity, despite decades-long preference for subpectoral implant placement. This paper aims to compare patient-reported outcomes (PRO) between prepectoral and subpectoral approaches to implant-based breast reconstruction (IBBR). The primary PRO was with the BREAST-Q, and postoperative pain scores, while the secondary outcomes were complication rates.

METHODS

A comprehensive literature search of the PubMed library was performed. All studies on patients undergoing IBBR after mastectomy that compared prepectoral to subpectoral placement and PROM or postoperative pain were included.

RESULTS

A total of 3789 unique studies of which 7 publications with 216 and 332 patients who received prepectoral and subpectoral implants, respectively, were included for meta-analysis. Patients with prepectoral implant placement had significantly higher satisfaction with the outcome (p = 0.03) and psychosocial well-being (p = 0.03) module scores. The pain was lower in patients with prepectoral implants on postoperative day 1 (p<0.01) and day 7 (p<0.01). The subgroup analysis of prepectoral breast implants showed that complete acellular dermal matrix coverage had lower rates of wound dehiscence (p<0.0001), but there were no significant differences in complications between one-stage and two-stage procedures.

CONCLUSION

Overall, patients with prepectoral implants reported higher BREAST-Q scores and lower postoperative pain and lower complications rates than patients with subpectoral implants. In appropriately selected patients, prepectoral implant placement with ADM coverage, be it the primary placement of an implant or placement of a tissue expander before definitive implant placement, should be the modality of choice in patients who choose IBBR. Further research should focus on patient selection, strategies to reduce cost and cost-benefit analysis of PIBR.

≠Risk of breast implant removal after one- versus two-stage breast reconstructive surgery

BACKGROUND

To date, both one- and two-stage techniques are used in immediate 'implant-based breast reconstruction' (IBBR) after mastectomy. Because it is still unknown what technique offers the best clinical outcomes, a multicenter retrospective study was conducted to compare both breast reconstruction techniques.

METHODS

All patients, who underwent a mastectomy followed by immediate one- or two-stage IBBR during 2010 - 2016 were included. Our primary outcome measure was explantation of the 'tissue expander' (TE) and/ or implants within 60 days after breast reconstruction. Secondary outcomes were overall complication rate and secondary corrections.

FINDINGS

Among a total of 383 women, TE/ implant explantation rate was higher in one-stage (19.9%) than in two-stage (11.3%) treated patients (p = 0.082). Overall complication rate (35.7% and 19.9% respectively, p = 0.008) and secondary corrections (29.8% and 20.3% respectively, p = 0.156) were also higher in one-stage compared to two-stage IBBR respectively. However, explantation (OR = 1.55; 95%CI = 0.67-3.58, p = 0.301) and complication (OR = 1.85; 95%CI = 0.92-3.37, p = 0.084) rates were comparable in one- and two-stage IBBR in our stratified multivariate logistic regression analyses, when controlling for history of smoking, nipple-sparing mastectomy, neoadjuvant radiation therapy, and removed breast tissue weight. A remarkable outcome in this study is that women treated with prophylactic surgery were more likely to have an explantation of the TE/ implant after a one-stage IBBR (OR = 4.49; 95%CI = 1.10-18.3, p = 0.037) than two-stage IBBR. In contrast, no association between type of IBBR and risk of TE/implants removal was found among women with a therapeutic mastectomy (OR = 0.82; 95%CI = 0.24-2.79, p =  = 0.74).

CONCLUSION

One- and two-stage IBBR showed a comparable explantation and complication rate in our retrospective study. In one-stage IBBR more secondary corrections were detected. In addition, women who have to decide on a prophylactic mastectomy should be aware of a significantly higher risk of explantation of their implant after one-stage IBBR.

Prevention of Breast Implant Displacement Using the Acellular Dermal Matrix Garter Belt

BACKGROUND

Since the issue of breast implant-associated anaplastic large cell lymphoma, smooth breast implants tend to be the more preferred option in implant-based breast reconstructions, compared to its use previously. The most unfavorable aspect of smooth implants is lateral and inferior displacements, which are more common in patients who undergo breast reconstruction compared to augmentation mammoplasty. Hence, we introduce a prevention method for implant displacement using an acellular dermal matrix garter belt.

METHODS

This study is a retrospective review of patients who had undergone implant-based breast reconstruction between April 2019 and December 2020. Some patients who have highly possibility of implant displacement, had undergone the application of an ADM garter belt to prevent lateral or superior displacement. Implant displacement was assessed before and at least 6 months postoperatively.

RESULTS

A total of 155 IBR cases were recorded. ADM garter belts were applied in 27 patients (17.4%) who had a high tendency of implant displacement for several reasons, which could be classified into two categories: wide breast pocket (56%) and tight inferomedial breast pocket (44%). The intraoperative average distance of lateral slipping on patients' reconstructed breasts from the chest wall midline in supine position was 3.02 ± 0.81 cm and corrected to1.54 ± 0.69 cm at least 6 months postoperative follow-up.

CONCLUSIONS

We utilized an ADM strap as an internalized garter belt to minimize implant displacement. This ADM garter belt combined with capsuloplasty might be an effective way to prevent the displacement of smooth implants in the patients with a greater risk of implant displacement.

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.

Long-Term Outcome of Nipple Projection Maintenance After Reconstruction with Clover Flap Technique

BACKGROUND

Nipple reconstruction using local skin flap leaves no morbidity in the healthy nipple. However, one disadvantage of this procedure is that the projection is not often maintained. There are few reports on the rate of long-term maintenance of nipple projection. This study aimed to analyze the 5-year results of clover flap (C-F) nipple reconstruction to determine whether it can be used to maintain nipple projection for long periods and to investigate the factors involved in maintenance of nipple projection.

METHODS

Patients that underwent nipple-areola reconstruction using C-F after undergoing a two-stage implant-based breast reconstruction with skin-sparing mastectomy between January 2012 and December 2019 were included. The projection of the reconstructed nipple was measured annually for 5 years postoperatively, and the nipple projection maintenance rate (%) was calculated. The influence of eight factors, namely smoking, irradiation, scarred skin, flap pedicle relative to the mastectomy scar, location of the mastectomy scar, flap suturing, and flap necrosis, on nipple height were evaluated.

RESULTS

Overall, 275 patients were enrolled. The average maintenance rates (%) at 1-5 years after surgery were 47.1, 39.8, 36.4, 34.6, and 33.5. Creating a well-vascularized skin flap, designing the pedicle farther away from the mastectomy scar, choosing a surgical technique involving an oblique scar on the side of the nipple by wrapping the skin flaps, and including an appropriate amount of fat tissue inside the reconstructed nipple are important for nipple projection maintenance.

CONCLUSION

Nipples reconstructed using the C-F technique on the artificial mound achieve excellent long-term result.

LEVEL OF EVIDENCE IV

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 .

Correlation analysis of resected breast tissue and implant volume after mastectomy and its association with breast density

BACKGROUND

The current methods for calculating the ideal implant volume for breast reconstruction are based on pre- or intraoperative volume measurements of the existing breast volume and do not take into account the individual breast density of the woman. This study aims is to identify objective parameters that can help to improve the optimal implant selection.

MATERIALS AND METHODS

This retrospective analysis includes 198 breast cancer patients who underwent mastectomy. Breast densities (ACR) measured in mammography and MRI were compared with the removed breast tissue weight and volume of the implants used. In addition, the resected weight was compared directly with the implant volume to calculate a mathematical function.

RESULTS

There was no significant correlation between the ACR values and the resected weights [correlation coefficient: mammography:- 0.117 (p = 0.176), MRI - 0.033 (p = 0.756)]. A negative correlation between the implant volumes and both imaging methods could be demonstrated [correlation coefficient: mammography - 0.268; p = 0.002; MRI was - 0.200 (p = 0.055)]. A highly significant correlation between the resected weights and the implant volumes (correlation coefficient 0.744; p < 0.001) was observed. This correlation corresponds to a power function (y = 34.71 x^0.39), in which any resected weight can be used for the variable x to calculate the implant volume.

CONCLUSION

We were able to show that there is a significant correlation between the resected breast tissue and the implant volume. With our novel potency function, the appropriate implant volume can be calculated for any resected weight making it easier for the surgeon to choose a fitting implant in a simple and more objective manner.

Risk factors of local recurrence following implant-based breast reconstruction in breast cancer patients

BACKGROUND

The number of patients desiring implant-based breast reconstruction has been increasing. While local recurrence is observed in patients with breast reconstruction, only a few reports have focused on the risk factors for local recurrence and the prognosis after developing local recurrence.

METHODS

We analyzed 387 patients who underwent implant-based breast reconstruction during the period from 2004 to 2017 in Hiroshima City Hospital. We retrospectively examined the risk factors for local recurrence and the outcomes of patients developing such recurrence after implant-based breast reconstruction.

RESULTS

The median follow-up time was 59 months. The local recurrence rate was 3.1% (n = 12). The most common reason for detecting local recurrence was a palpable mass. Four patients with local recurrence had recurrence involving the skin just above the primary lesion and needle biopsy tract. All patients with local recurrence received surgery and systemic therapy and most patients received radiation therapy, all have remained free of new recurrence to date. Multivariate analysis showed lymphatic vessel invasion (HR, 6.63; 95% CI, 1.40-31.36; p = 0.017) and positive or < 2 mm vertical margin (HR, 9.72; 95%CI, 1.23-77.13; p = 0.047) to be associated with significantly increased risk of local recurrence.

CONCLUSIONS

The risk factors for local recurrence following implant-based breast reconstruction were lymphatic vessel invasion and positive or < 2 mm vertical margin. Removal of the skin just above the primary lesion and needle biopsy tract and adjuvant radiation therapy might improve local outcomes. Patients with local recurrence following implant-based breast reconstruction appear to have good outcomes with appropriate treatment.

Acellular bovine pericardium matrix in immediate breast reconstruction compared with conventional implant-based breast reconstruction

Background

Acellular Bovine Pericardium Matrix (ABPM) is a new material in implant-based breast reconstruction (IBBR). Few studies have reported on its outcome and complications worldwide and most studies were without a control group. Our aim was to compare its use in IBBR with the other two conventional implant-based reconstruction methods.

Methods

A retrospective review of patients undergoing IBBR from January to December 2018 was performed. Patients were assigned to the ABPM-assisted IBBR (group A), latissimus dorsi-assisted IBBR (group B) and two-stage IBBR (group C). Patients’ post-operative complications, cost-effectiveness and Quality of Life were compared.

Results

100 patients with 100 breasts were included in the study. No complications occurred in group C (n = 11). No significant differences were noted between group A (n = 44) and group B (n = 45) in terms of overall complications (9.1% vs 11.1%, p = 0.973). Group B had the longest operative duration (310.8 ± 62.3 min, p<0.001). The cost of hospitalization forthe three groups was $8051.3 ± 849.2, $7566.0 ± 1172.7 and $7896.5 ± 1762.2, respectively (p = 0.128). The postoperative Breast-Q scores  were similar across the three groups.

Conclusions

ABPM demonstrated acceptable complication rates, cost-effectiveness and quality of life outcomes when compared to LD-assisted IBBR and two-stage IBBR.

Clinical outcomes of patients after nipple-sparing mastectomy and reconstruction based on the expander/implant technique

Advances in multi-modality treatments incorporating systemic chemotherapy, endocrine therapy, and radiotherapy for the management of breast cancer have resulted in a surgical-management paradigm change toward less-aggressive surgery that combines the use of breast-conserving or -reconstruction therapy as a new standard of care with a higher emphasis on cosmesis. The implementation of skin-sparing and nipple-sparing mastectomies (SSM, NSM) has been shown to be oncologically safe, and breast reconstructive surgery is being performed increasingly for patients with breast cancer. NSM and breast reconstruction can also be performed as prophylactic or risk-reduction surgery for women with BRCA gene mutations. Compared with conventional breast construction followed by total mastectomy (TM), NSM preserving the nipple-areolar complex (NAC) with breast reconstruction provides psychosocial and aesthetic benefits, thereby improving patients' cosmetic appearance and body image. Implant-based breast reconstruction (IBBR) has been used worldwide following mastectomy as a safe and cost-effective method of breast reconstruction. We review the clinical evidence about immediate (one-stage) and delayed (two-stage) IBBR after NSM. Our results suggest that the postoperative complication rate may be higher after NSM followed by IBBR than after TM or SSM followed by IBBR.

Development of an evidence-based approach to the use of acellular dermal matrix in immediate expander-implant-based breast reconstruction

BACKGROUND

Although acellular dermal matrix (ADM) is widely used in expander-implant-based breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM procedures. This study aims to develop a more selective, evidence-based approach to the use of ADM in expander-implant-based breast reconstruction by identifying patient subgroups in which ADM improved clinical outcomes and PROs.

STUDY DESIGN

The Mastectomy Reconstruction Outcomes Consortium Study prospectively evaluated immediate expander-implant reconstructions at 11 centers from 2012 to 2015. Complications (any/overall and major), and PROs (satisfaction, physical, psychosocial, and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age, body mass index, radiation timing, and chemotherapy.

RESULTS

Expander-implant-based breast reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. nonusers (22.9% vs. 16.4% and p = 0.04). Major complication risk with ADM increased with higher BMI (BMI=30, OR=1.70; BMI=35, OR=2.29, interaction p = 0.02). No significant ADM effects were observed for breast satisfaction, psychosocial, sexual, and physical well-being within any subgroups.

CONCLUSION

In immediate expander-implant-based breast reconstruction, ADM was associated with a greater risk of major complications, particularly in high-BMI patients. We were unable to identify patient subgroups where ADM was associated with significant improvements in PROs. Given these findings and the financial costs of ADM, a more critical approach to the use of ADM in expander-implant reconstruction may be warranted.

Immediate one-stage implant-based breast reconstruction without the use of acellular dermal matrix in Japanese breast cancer patients

BACKGROUND

In immediate one-stage implant-based breast reconstruction, acellular dermal matrix (ADM) is widely used around the world due to its ability to cover the outside part of the pectoralis major muscle. Unfortunately, ADM has not yet been approved in Japan. Consequently, in our institution, we have performed safe one-stage implant-based breast reconstruction without ADM by employing several unique techniques and have obtained excellent results.

METHODS

The data of 186 patients were reviewed. In each case, we performed three unique steps to determine which cases were suitable for one-stage implant-based breast reconstruction as follows. First, ICG fluorescence imaging was performed to confirm the blood flow of the skin after mastectomy. Next, a serratus anterior muscle/fascial and external oblique fascial flap was elevated to completely cover the implant together with the pectoralis major muscle. We used a sizer to confirm the skin tension and the form of the breast. After confirming correct size, shape and coverage, we selected cases in which implant could be safely performed. We evaluated the final cosmetic outcome based on three measurements: the inframammary fold position, and the bilateral balance of both breast size and form.

RESULTS

The rate of immediate one-stage implant-based reconstruction was 85.7%. An implant was removed in one case because of complications, and infection developed in five cases. Among all patients, the overall cosmetic evaluation of the final outcome was evaluated as good, fair and poor in 84.3%, 13.5% and 2.2% of cases, respectively.

CONCLUSIONS

Immediate one-stage implant-based breast reconstruction without ADM can be a useful and safe procedure, based on our unique techniques in breast cancer patients who hope for immediate prosthetic breast reconstruction in Japan.

Significantly reducing implant loss rates in immediate implant-based breast reconstruction: A protocol and completed audit of quality assurance

INTRODUCTION

Immediate implant-based breast reconstruction (IBR) rates have increased considerably with the advent of acellular dermal matrices. Implant loss is a significant complication and is costly to patients and the NHS. National Mastectomy and Breast Reconstruction Audit and Implant-Based Breast Reconstruction Audit data have demonstrated national implant loss rate of 9% at 3 months. National Oncoplastic Guidelines for Best Practice cite a < 5% target. We aimed to reduce implant loss by introducing a protocol with pre-, intra- and post-operative interventions.

METHODS

Audit of IBR at a single oncoplastic breast unit was commenced and implant loss at 3 months was recorded (May 2012-July 2014). Patients were identified from a prospectively maintained database, and case notes were examined by identifying factors associated with implant loss. A team involving microbiology, theatre staff, infection control and surgeons was established. A novel, evidence-based intervention bundle, including more than 25 protocol changes, was introduced. Prospective re-audit of IBR (April 2015-December 2017) was completed following introduction of the new protocol and implant loss was recorded at 3 months.

RESULTS

The first retrospective audit of 77 reconstructions (54 patients) demonstrated 11 implant losses at 3 months (14%). Re-audit, post-intervention, comprised 129 reconstructions (106 patients) with no implant loss at 3 months. Fisher's exact analysis revealed statistically significant reduction in implant loss rate (P < 0.00001) following protocol introduction.

CONCLUSIONS

Implant loss rate following IBR can be reduced to an exceptionally low level, well below national targets, by adhering to this evidence-based intervention bundle. Our protocol could improve outcomes nationally.

Breast sensibility after mastectomy and implant-based breast reconstruction

PURPOSE

The aim of the study is to evaluate the level of sensible impairment after mastectomy or implant-based breast reconstruction (IBBR). In addition, factors influencing breast sensibility were evaluated.

METHODS

A cross-sectional study was performed in Maastricht University Medical Center between July 2016 and August 2018. Women with unilateral mastectomy with or without IBBR were included. Objective sensory measurements were performed using Semmes-Weinstein monofilaments. Their healthy breast served as control, using a paired t test. Differences between mastectomy with and without IBBR were evaluated using the independent t test. Linear regression was performed to evaluate the association between patient characteristics on breast sensibility. The paired t test was used to evaluate in which part of the breast the sensibility is best preserved.

RESULTS

Fifty-one patients were eligible for inclusion. Sixteen patients underwent IBBR after mastectomy. Twenty-three patients received radiotherapy and 35 patients received chemotherapy. Monofilament values were significantly higher in the operated group compared to the reference group (p < 0.001). Linear regression showed a statistically significant association between IBBR and objectively measured impaired sensation (p = 0.008). After mastectomy, the cutaneous protective sensation is only diminished. After IBBR, it is lost in the majority of the breast. The medial part of the breast was significantly more sensitive than the lateral part in all operated breasts (p < 0.001).

CONCLUSION

IBBR has a significantly negative impact on the breast sensibility compared to mastectomy alone. This study shows that the protective sensation of the skin in the breast is lost after IBBR. To our knowledge, this is the first study to evaluate the level of sensible impairment after mastectomy or IBBR. More research is necessary to confirm these results.

Characterizing infections in prosthetic breast reconstruction: A validity assessment of national health databases

INTRODUCTION

Current guidelines in the United States require reporting only the 30-day postoperative outcomes to standardized databases, including the National Surgical Quality Improvement Program (NSQIP). Thus, many breast implant-related complications go unreported in standard databases. We sought to characterize late periprosthetic infections following implant-based breast reconstruction.

METHODS

We conducted a retrospective analysis of all women who underwent expander/implant reconstruction from 2005 to 2014 at two institutions. All periprosthetic infections were identified and divided into early and late cohorts (≤30 days or >30 days). Infection was defined as any episode where antibiotics were initiated or a prosthetic device was explanted because of clinical evidence of the infection.

RESULTS

In the 1820 patients (2980 breasts) identified, 421 periprosthetic infections occurred (14%). Of these, 173 (41%) were early and 248 (59%) were late (mean time to infection = 66.4 ± 101.9 days). Patients with late infections were more likely to be current smokers or have diabetes than patients with early infections (p < 0.034 for both). Infections caused by gram-negative bacteria and antimicrobial-resistant strains of Staphylococcus were more common in the early infection group (p < 0.001 for both). Implant loss due to infection was more common in the late infection group (p = 0.037).

DISCUSSION

Late periprosthetic infections following implant-based breast reconstruction are underestimated in national outcome databases and have unique risk factors and microbiology compared to early infections. A system-level change in reevaluating and redefining a timeline for tracking and treating implant infections is necessary, given the substantial morbidity associated with, and frequency of, late periprosthetic infections.

Nipple reconstruction after implant-based breast reconstruction in radiated patients: A new safe dermal flap

INTRODUCTION

After implant-based breast reconstruction, the nipple reconstruction technique must be carefully chosen, especially in patients with a history of radiotherapy. When the contralateral nipple is not available, using a classical dermal-fat local flap may lead to the implant exposure, and consequently, removal. We describe here a simple nipple reconstruction technique, using a strictly dermal local flap and evaluate its complication rate.

PATIENTS AND METHODS

All patients who underwent our technique for nipple reconstruction between January 2012 and April 2015 were included in this retrospective study. We described our surgical technique and noted the occurrence of postoperative complications.

RESULTS

Forty-nine nipples, in 47 patients with a history of radiotherapy, were reconstructed with our technique. The mean age was 53 years old (range 27-78 years old). The average time between radiotherapy and nipple reconstruction was 42.5 months (range from 4.6 to 274.8 months). The mean follow-up was 30.9 months (range from 6 to 47 months). No implant exposure occurred. Regarding the nipple flap, two partial flap loss and one infection occurred, the whole complication rate was 6.1%. Regarding nipple projection, it was quite low (between 2 and 5 mm) after 6 months, but remained stable.

CONCLUSION

Our strictly dermal local flap technique for nipple reconstruction is a safe procedure and represents a good alternative to composite contralateral nipple graft in irradiated patients with an implant-based reconstructed breast.

TiLoop® Bra mesh used for immediate breast reconstruction: comparison of retropectoral and subcutaneous implant placement in a prospective single-institution series

BACKGROUND

Immediate implant reconstruction after a conservative mastectomy is an attractive option made easier by prosthetic devices. Titanized polypropylene meshes are used as a hammock to cover the lower lateral implant pole. We conducted a prospective nonrandomized single-institution study of reconstructions using titanium-coated meshes either in a standard muscular mesh pocket or in a complete subcutaneous approach. The complete subcutaneous approach means to wrap an implant with titanized mesh in order to position the implant subcutaneously and spare muscles.

METHODS

Between November 2011 and January 2014, we performed immediate implant breast reconstructions after conservative mastectomies using TiLoop® Bra, either with the standard retropectoral or with a prepectoral approach. Selection criteria included only women with normal Body Mass Index (BMI), no large and very ptotic breasts, no history of smoking, no diabetes, and no previous radiotherapy. We analyzed short-term outcomes of such procedures and compared the outcomes to evaluate implant losses and surgical complications.

RESULTS

A total of 73 mastectomies were performed. Group 1 comprised 29 women, 5 bilateral procedures, 34 reconstructions, using the standard muscular mesh pocket. Group 2 comprised 34 women, 5 bilateral procedures, 39 reconstructions with the prepectoral subcutaneous technique. Baseline and oncologic characteristics were homogeneous between the two groups. After a median follow-up period of 13 and 12 months, respectively, no implant losses were recorded in group 1, and one implant loss was recorded in group 2. We registered three surgical complications in group 1 and two surgical complications in group 2.

CONCLUSIONS

Titanium-coated polypropylene meshes, as a tool for immediate definitive implant breast reconstruction, resulted as safe and effective in a short-term analysis, both for a retropectoral and a totally subcutaneous implant placement. Long-term results are forthcoming. A strict selection is mandatory to achieve optimal results. Level of Evidence: Level II, therapeutic study.