Impact of mastectomy flap necrosis on prepectoral reconstructive outcomes

INTRODUCTION

As reconstructive surgeons have increasingly transitioned to the prepectoral plane for prosthetic breast reconstruction, the implications of mastectomy skin flap necrosis have become more concerning. Our goal was to evaluate the effect of skin flap necrosis on reconstructive outcomes in patients undergoing immediate prepectoral breast reconstruction.

METHODS

A retrospective review was conducted of patients undergoing immediate two-stage prepectoral reconstruction at a single center with at least 3 months follow-up. Postoperative complications, reconstructive outcome, and time to final implant were compared between patients with and without mastectomy skin necrosis.

RESULTS

A total of 301 patients underwent 509 prepectoral breast reconstructions. Forty-four patients (14.6%) experienced postoperative mastectomy skin flap necrosis. Demographic and reconstructive characteristics were similar between the necrosis and no necrosis cohorts. Patients with skin necrosis were more likely to undergo reoperation after tissue expander (64% vs 19%, p < 0.01) and undergo expander replacement (13.6% vs 3.5%, p = 0.02). However, rates of reconstructive failure (6.8% vs 6.2%), major infection (9.1% vs 9.0%), and minor infection (13.6% vs 17.5%) after expander placement were statistically similar. Patients with skin necrosis trended toward longer time before final implant placement, although the difference was not statistically significant (6.5 vs 5.0 months, p = 0.08). There was no difference in complication rates between the necrosis and no necrosis cohort after final implant placement. There was a higher rate of revision surgery after implant placement in the necrosis cohort (12.5% vs 4.1%, p = 0.047).

CONCLUSIONS

Mastectomy skin flap necrosis is a concerning postoperative event, particularly in patients with prepectoral prostheses. We observed that patients with skin necrosis experience higher reoperation rates in the expander period, yet have similar infection rates and achieve similar final reconstructive outcomes compared to patients without necrosis.

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results

INTRODUCTION

Current breast cancer treatment trends advocate nipple-sparing mastectomy (NSM) as the preferred technique for selected patients. A considerable and ptotic breast is often considered a relative contraindication for NSM due to the increased risk of skin and nipple necrosis.

METHODS

A retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts eligible for NSM for therapeutic or prophylactic purpose. Exclusion criteria comprised a preoperative nipple-sternal notch distance greater than 30 cm, previous radiotherapy, pinch test <1 cm, body mass index (BMI) greater than 34 and active smoke. We present our short-term results with this technique.

RESULTS

During the study period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years [The Interquartile Range (IQR 50.0-68.6)] with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472 g (341-578). Median implant volume was 465 g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients experienced total nipple-areolar complex (NAC) necrosis (3.9%), and partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p = 0.003).

CONCLUSION

If oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

Outcomes after tissue expander exchange to implant in two-stage prepectoral breast reconstruction with and without acellular dermal matrix: A retrospective cohort study

As prepectoral implant placement becomes widely adopted, recent studies investigating the use of acellular dermal matrix (ADM) during tissue expander placement have demonstrated no major benefit with regard to postoperative outcomes. We sought to evaluate second-stage outcomes 1 year after tissue expander exchange to implant with and without ADM. Consecutive patients who underwent prepectoral tissue expander-based breast reconstruction with and without ADM were identified. Patients were followed up for 1 year after tissue expander exchange to implant. Second-stage outcomes of interest including implant rippling, capsular contracture, implant explantation, additional revision surgeries, and patient-reported outcomes were collected and compared. Sixty-eight breasts in the ADM cohort and sixty-one breasts in the no ADM cohort underwent tissue expander exchange to implant. Second-stage outcomes of interest were similar between the ADM and no ADM cohorts with no statistically significant differences identified regarding incidences of implant rippling (24.6% vs. 12.1%, p = 0.08), capsular contracture (4.5% vs. 3.3%, p = 1.00), and explantation (6.6% vs. 1.7%, p = 0.67) between the two cohorts. BREAST-Q scores were similar between the two cohorts with the exception of physical wellbeing and satisfaction in terms of implant rippling, as can be seen, which improved in the no ADM cohort (p = 0.04). Our study reports no major benefit for the inclusion of ADM with respect to implant rippling, capsular contracture, explantation, need for additional revision surgeries, and patient-reported satisfaction in prepectoral second-stage implant-based breast reconstruction.

Difference in the outcomes of anterior tenting and wrapping techniques for acellular dermal matrix coverage in prepectoral breast reconstruction

BACKGROUND

Acellular dermal matrices (ADMs) play an essential role in prepectoral implant-based breast reconstructions; however, the most appropriate method for ADMs is unknown.

METHODS

We conducted a retrospective analysis of our institutional database. Patients who underwent mastectomy and prepectoral breast reconstruction using tissue expanders or breast implants covered with ADMs between March 2018 and June 2021 were included. Patient characteristics, postoperative complications, and long-term outcomes were investigated.

RESULTS

In total, 112 patients (126 breasts) were included. The anterior tenting and wrapping techniques were used in the reconstruction of 32 (25.3%) and 94 (74.7%) breasts, respectively. Using propensity score matching, nine breasts were selected for each technique within the direct-to-implant reconstruction group, while 16 breasts were selected for each technique within the 2-stage reconstruction group. The choice of technique (anterior vs. wrapping) in implementing ADM did not generate any significant differences in postoperative complications, including seroma formation and capsular contracture, for the direct-to-implant and 2-stage reconstruction groups. Regarding the direct-to-implant reconstruction group, the average postoperative drain volume was less in the anterior tenting group than that in the wrapping group (anterior tenting vs. wrapping; 495.09 ± 156.118 mL vs. 673.43 ± 307.954 mL, p = 0.006), but the difference was insignificant after propensity score matching.

CONCLUSION

We report our experience with covering prosthetic devices with ADMs during postmastectomy breast reconstruction. No differences in the postoperative drain volume or postoperative outcomes were found between the study groups. Future studies are needed to determine the method that provides the most satisfactory results.

Predicting Mastectomy Skin Flap Necrosis: A Systematic Review of Preoperative and Intraoperative Assessment Techniques

Mastectomy skin-flap necrosis (MSFN) is one of the most feared complications of immediate implant-based breast reconstruction (IIBR). Traditionally, mastectomy skin-flap viability was based only on surgeons' clinical experience. Even though numerous studies have already addressed the patients' risk factors for MSFN, few works have focused on assessing quality of breast envelope. This review investigates mastectomy's flap viability-assessment methods, both preoperative (PMFA) and intraoperative (IMFA), to predict MSFN and its sequalae. Between June and November 2022, we conducted a systematic review of Pubmed/MEDLINE and Cochrane electronic databases. Only English studies regarding PMFA and IMFA applied to IIBR were selected. The use of digital mammography, ultrasound, magnetic resonance imaging, and a combination of several methods before surgery was shown to be advantageous by several authors. Indocyanine performed better than other IMFA, however both thermal imaging and spectroscopy demonstrated novel and promising results. Anyway, the best prediction comes when preoperative and intraoperative values are combined. Particularly in prepectoral reconstruction, when mastectomy flaps are essential to determine a successful breast reconstruction, surgeons' clinical judgment is insufficient in assessing the risk of MSFN. Preoperative and intraoperative assessment techniques play an emerging key role in MSFN prediction. However, although there are several approaches to back up the surgeon's processing choice, there is still a dearth of pertinent literature on the subject, and more research is required.

Prepectoral Breast Reconstruction

Prepectoral breast reconstruction has gained popularity due to numerous benefits in properly selected patients. Compared with subpectoral implant reconstruction, prepectoral reconstruction offers preservation of the pectoralis major muscle in its native position, resulting in decreased pain, no animation deformity, and improved arm range of motion/strength. Although prepectoral reconstruction is safe and effective, the implant sits closer to the mastectomy skin flap. Acellular dermal matrices play a critical role, allowing for precise control of the breast envelope and providing long-term implant support. Careful patient selection and intraoperative mastectomy flap evaluation are critical to obtaining optimal results with prepectoral breast reconstruction.

Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio

We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast).

BACKGROUND

The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction.

METHODS

We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data.

RESULTS

The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).

A Pure Autologous Dermal Graft and Dermal Flap Pocket in Prepectoral Implant Reconstruction After Skin-Reducing Mastectomy: A One-Stage Autologous Reconstruction Alternative to Acellular Dermal Matrices

Skin-reducing mastectomy (SRM) with subpectoral implant positioning represents a consolidated, oncologically safe and cosmetically effective method for the immediate reconstruction of large and ptotic breasts. Acellular dermal matrix (ADM) has been proposed as a substitute for the pectoralis major muscle in this surgical approach; this technique led to a progressive evolution toward prepectoral reconstructions even in skin-reducing mastectomies. Obese patients with macromastia who are typical candidates for SRM with ADM are at increased risk of complications associated with ADMs. Therefore, we avoided ADMs and developed a novel autologous technique for immediate breast reconstruction in large and ptotic breasts eligible for SRM. Specifically, an autologous dermal graft is harvested from contralateral healthy breast reduction to cover the upper pole of the prepectoral implant.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 .

Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy

BACKGROUND

Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT.

METHODS

We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted.

RESULTS

We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events.

CONCLUSIONS

Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.

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.

Prepectoral implant-based breast reconstruction with TiLOOP® Bra Pocket - a single-centre retrospective study

BACKGROUND

Prepectoral implant-based reconstruction using synthetic meshes is feasible with good outcomes. We present our data using TiLOOP® Bra Pocket, a novel ready-to-use mesh pocket which acts as an internal bra and prevents the implant from dislocating or twisting.

MATERIALS AND METHODS

A single-centre retrospective cohort study was performed to assess short-term complication rates and cosmetic outcomes in patients with prepectoral implant-based reconstruction using the TiLOOP® Bra Pocket. The primary endpoint was complication rates during the first 6 months. The secondary endpoint was the cosmetic outcome after 6 to 12 months, which was judged by two breast surgeons using the Harvard score.

RESULTS

A total of 63 breasts (43 patients) were reconstructed using the TiLOOP® Bra Pocket between 2018 and 2020, 57 were immediate reconstructions. The overall complication rate was 30,2% (n = 19/63). Major complications occurred in seven breasts (n = 7/63; 11,1%) and minor complications occurred in 12 breasts (12/63; 19,0%). The unplanned revision rate was 12,7%. The cosmetic outcome was good (Harvard score: mean 3, range 1-4; SD 0,75). Seventeen cosmetic complications were observed (17/63; 27,0%) and six cosmetic revision surgeries were performed (6/63; 9,5%).

CONCLUSION

The use of the TiLOOP® Bra Pocket is convenient and standardized because the pocket is preformed and does not require to be sewn first. Cosmetic outcome is good; however, the surgical morbidity needs to be addressed in future reconstructions. Careful patient selection and preparation techniques are vital in order to achieve acceptable complication rates and satisfying cosmetic results.

Direct to Implant Breast Reconstruction With Prepectoral Micropolyurethane Foam-Coated Implant: Analysis of Patient Satisfaction

BACKGROUND

Immediate implant reconstruction after mastectomy with submuscular implant placement is widely used in order to avoid implant exposure, capsular contracture and poor aesthetic result. Postoperative complications can be reduced by maintain mastectomy flap thickness and asses flap vascularity with near infrared imaging. The prepectoral reconstruction with polyurethane implants has been utilized with encouraging results. Postoperative patient satisfaction was assessed with the BREAST-Q scores in patients who underwent prepectoral reconstruction with polyurethane implants. Additionally the impact of mastectomy flap thickness on breast reconstruction was investigated.

MATERIALS AND METHODS

The Breast Q-scores of satisfaction with the breast, the postoperative outcome and physical well-being of the chest in 70 patients underwent immediate implant breast reconstructions with prepectoral polyurethane implant were retrospectively reviewed. The correlation between mastectomy flap thickness and satisfaction with breast was analyzed.

RESULTS

At 12-month follow-up the mean Q-score for satisfaction with breast was 71.73 (standard deviation: 13.31), and for physical well-being chest was 70.73 (standard deviation: 7.94). A positive linear correlation between mastectomy flap thickness and satisfaction with the breast was identified.

CONCLUSIONS

The postoperative Q-scores are encouraging in the use of polyurethane prepectoral implants in immediate breast reconstruction, especially in patients with "thick" mastectomy flaps.

Prepectoral breast reconstruction

Implant-based breast reconstruction is the most commonly used reconstruction technique after mastectomy. This is because skin-sparing mastectomy has become possible with advancements in oncology. In addition, the development of breast implants and the advent of acellular dermal matrices have reduced postoperative complications and resulted in superior cosmetic results. The most frequently performed surgical breast reconstruction procedure for the past 20 years was the insertion of an implant under the pectoralis major muscle by means of the dual plane approach. However, some patients suffered from pain and animation deformity caused by muscle manipulation. Recently, a prepectoral approach has been used to solve the above problems in select patients, and the results are similar to subpectoral results. However, this technique is not always chosen due to the number of considerations for successful surgery. In this article, we will discuss the emergence of prepectoral breast reconstruction, indications and contraindications, surgical procedures, and outcomes.

Implant selection in the setting of prepectoral breast reconstruction

Implants vary in width, height, projection, volume, fill consistency, shell surface, and shape. Given the wide variety of implants that are available, selecting an implant that best suits a patient can be challenging. This article reviews the principles governing implant selection. Based on the authors' clinical experience, an algorithm for implant selection is proposed.

Prepectoral breast reconstruction and radiotherapy-a closer look

Background

Prosthetic breast reconstruction in the setting of post-mastectomy radiation therapy (PMRT) has historically been plagued by complications and poor outcomes. We study the effects of PMRT in the setting of prepectoral prosthetic breast reconstruction in an attempt to ascertain the value of this muscle sparing technique as it relates to complications and outcomes.

Methods

A retrospective analysis was performed on patients who underwent immediate, prepectoral, direct-to-implant or two-staged expander/implant breast reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and had postmastectomy radiotherapy. Results and complications were recorded.

Results

In patients who underwent two-staged reconstruction, at the second stage, on visual inspection, the acellular dermal matrix was noted to be completely integrated in all breasts, including those that had been irradiated after expander placement. Postoperative complications in irradiated breasts were limited to two breasts. In one breast, there was one incidence of wound dehiscence after expander irradiation, which led to expander removal and salvage with transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. In the second breast, there was one incidence of seroma after implant irradiation, which was managed conservatively as an outpatient. The seroma was drained and the patient treated with oral antibiotics. There were no complications in nonirradiated breasts. There was no incidence of clinically significant capsular contracture (grade III/IV) in irradiated or nonirradiated breasts.

Conclusions

Prepectoral breast reconstruction has been an important addition to our reconstructive armamentarium and is proving to be a safe and effective means of performing prosthetic breast reconstruction in a wide array of patient populations. We have seen excellent physiologic and aesthetic outcomes in our patients following PMRT with minimal complications. Indeed, long-term follow-up will be required to elucidate the true effectiveness of this technique but preliminary results are quite promising.