Identification of complications in mastectomy with immediate reconstruction using tissue expanders and permanent implants for breast cancer patients

Evaluating the Effect of Preoperative Provision of Information on Salivary Cortisol in Patients Undergoing Breast Cancer Surgery: A Randomized Controlled Study

PURPOSE

Surgery is considered to be an anxious experience and most patients experience preoperative anxiety. Preoperative awareness has long been one of the most effective ways to reduce fear and anxiety caused by surgery. The aim of this study was to determine the effect of preoperative provision of information on salivary cortisol in candidates for breast cancer surgery.

DESIGN

This randomized clinical trial was conducted on 80 patients (divided into control group and intervention group; 40 patients in each group) admitted to the surgery department of the Cancer Institute of Imam Khomeini hospital in Iran. Samples were selected using random allocation method with a block size of four. Data were collected on participants' demographic characteristics and salivary cortisol.

METHODS

The educational intervention for patients in the control group was routine training and for patients in the intervention group was based on the training booklet approved by cancer specialists. Findings were analyzed using SPSS software version 21.

FINDINGS

The mean age of participants in the intervention and control groups was 44.00 ± 11.45 and 42.62 ± 12.83 years, respectively . The mean score of anxiety in the intervention group was 18.85± 6.19 before intervention, and decreased to 7.40± 3.68 after intervention . The mean score of anxiety in the control group was 19.75 ± 7.26 and significantly decreased to 14.25 ± 5.73 at the end of the study.

CONCLUSIONS

The results showed that preoperative anxiety significantly decreased in both groups, but was lower overall in the intervention group. In fact, using an educational booklet to raise awareness about patients' health, surgery knowledge and postoperative care as well as how to adapt to postsurgery physical changes and to promote psychological support can reduce patients' anxiety. Hence, providing education to patients may be integrated as a complementary method in patients' routine education.

Effect of obesity on outcomes after breast reconstruction surgery, an analysis of national surgical quality improvement program

BACKGROUND

Obesity is a risk factor for breast cancer and may affect the incidence, and outcomes of surgical treatment for breast cancer, including breast reconstruction.

OBJECTIVE

This study aimed to evaluate outcomes of breast reconstruction in patients with obesity.

METHODS

In a retrospective review of the NSQIP 2013-2018, adult patients who underwent breast reconstruction were included. Procedures were categorized to with or without an implant. Obesity was considered as body mass index(BMI)≥30 kg/m². We made composite variables for 30-day any complication, wound complications, and major complications. Regression analysis was used to identify the independent effect of obesity on outcomes.

RESULTS

A total of 46,042 patients were included(mean age 51.4 ± 11.1 years, 99.8% female). There were 3134(6.8%) patients with any complication, 2429(5.3%) with major, and 2772(6%) with wound complications, 2795 patients(6.1%) with unplanned re-operation, and 3 deaths. Obesity was an independent predictor of any complication, major complications, and wound complications(OR:1.83-1.87), and unplanned re-operation(OR:1.52). Wound complication was lower in the implant group(3.7% vs 10.9%) but obesity had a higher odds of wound complications in the implant group(2 vs 1.4). There was an increase in the odds of complications as BMI rises.

CONCLUSION

Patients with a BMI>30 kg/m2 have a significantly higher risk of developing surgical complications following breast reconstruction with both implant and tissue reconstruction. Weight loss strategies should be considered in patients who need breast reconstruction surgeries and this may decrease the risk of postoperative wound complication and the need for reoperation.

The Impact of Adjuvant Radiotherapy on Immediate Implant-based Breast Reconstruction Surgical and Satisfaction Outcomes: A Systematic Review and Meta-analysis

Adjuvant radiotherapy could be a necessary step in the oncological treatment for breast cancer. However, radiotherapy may have negative effects on implant-based immediate breast reconstruction. The aim of this study was to determine the impact of adjuvant radiation therapy on surgical results and patient-reported satisfaction outcomes in women undergoing immediate implant-based breast reconstruction.

Methods

A systematic search in PubMed was conducted on September 2019 and updated on April 2021. The risk of bias of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Observational Studies. RevMan 5 was used for statistical analysis. We obtained relative risks to determine the complication incidence and mean differences for 2-year BREAST-Q scores.

Results

Fourteen studies were included. A total of 11,958 implant-based immediate reconstructions were performed, 2311 received postmastectomy radiation therapy, and 9647 were considered as control group. Surgical complications, reoperation rates, and reconstruction failure were significantly higher among irradiated breasts. Significantly lower BREAST-Q scores were reported by irradiated women receiving radiotherapy.

Conclusions

This systematic review and meta-analysis combines reconstruction complication rates with aesthetic and patient-reported satisfaction outcomes. Adjuvant radiotherapy is consistently associated with greater complication rates and poorer aesthetic and satisfaction outcomes. The magnitude of association is significantly lower when the reconstruction is based on autologous tissues.

Reduction of seroma and improvement of quality of life after early drain removal in immediate breast reconstruction with tissue expander. Preliminary report from a randomized controlled study

Seroma is the most common complication of breast reconstruction with tissue expander (incidence 0.2-20%) with increased risk of infection and implant loss by 4-6 fold. About 90% of plastic surgeons routinely placed drains for its prevention. We theorized that early drain removal is a safe procedure that improves postoperative quality of life (QoL), reducing pain, length of hospital stay, and limitations on daily activities. We divided 49 patients operated on between September 2016 and March 2018 (follow-up: 9-26 months) into two groups: Group1 (output-based; drains removed when <30 ml/day); and Group2 (early-removal; at 3-4 days postop.). A study-specific questionnaire about the patient's QoL was conducted 3 weeks after surgery. We performed an intention-to-treat analysis. A comparison was performed using a Fisher test and a Mann-Whitney U test with p = 0.05. We observed lower production of wound fluid (641±49 ml vs 231±20 ml; p = 0.004), and a shorter time until wound healing (31.3±4.2 days vs 22±3.9 days; p = 0.031) for Group 2. The difference for infection (p = 0.36), impaired wound healing (p = 0.22), and the seroma formation period (p = 0.11) was not significant. Group 2 experienced less breast pain (8% vs 87.5%; p = 0.001), fewer limitations in daily activities (16% vs 50%; p = 0.002), in mobility (20% vs 83.3%; p = 0.001), and in social life (8% vs 91.7%; p < 0.001), and a better quality of sleep than Group 1 (36% vs 75%; p = 0.002). Group 2 did not require home care after hospital discharge (p < 0.001). The limitations of study are: its small sample size, the wound healing assessment, and the use of a non-validated questionnaire.

Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander?

BACKGROUND

Immediate breast reconstruction with tissue expander in breast cancer patients who were expected to receive adjuvant therapy, such as chemotherapy or radiotherapy, has been a topic of debate. Postoperative complications from tissue expander procedures can delay the timing of adjuvant treatment and subsequently increase the probability of recurrence. The purpose of this study was to identify the impact of chemotherapy and radiotherapy on postoperative complications in patients who underwent immediate reconstruction (IR) using tissue expander.

METHODS

We conducted a retrospective study of 1081 breast cancer patients who underwent mastectomy and IR using tissue expander insertion between 2012 and 2017 in Samsung Medical Center. The patients were divided into two groups based on complications (complication group vs. no complication group). Complication group was regarded to have surgical removal or conservative treatment based on clinical findings such as infection, capsular contracture, seroma, hematoma, rupture, malposition, tissue viability, or cosmetic problem. The complication group had 59 patients (5.5%) and the no complication group had 1022 patients (94.5%).

RESULTS

In univariate analysis, adjuvant radiotherapy and adjuvant chemotherapy were significantly associated with postoperative complications. In multivariate analysis, however, only higher pathologic N stage was significantly associated with postoperative complications (p < 0.001). Chemotherapy (p = 0.775) or radiotherapy (p = 0.825) were not risk factors for postoperative complications.

CONCLUSIONS

IR with tissue expander after mastectomy may be a treatment option even when the patients are expected to receive adjuvant chemotherapy or radiotherapy. These results will aid patients who are concerned about the complications of IR caused by chemotherapy or radiotherapy determine whether or not to have IR.

TRIAL REGISTRATION

Patients were selected and registered retrospectively, and medical records were evaluated.

Risk factors for tissue expander infection in scar reconstruction: a retrospective cohort study of 2374 consecutive cases

Background

Tissue expansion is used for scar reconstruction owing to its excellent clinical outcomes; however, the complications that emerge from tissue expansion hinder repair. Infection is considered a major complication of tissue expansion. This study aimed to analyze the perioperative risk factors for expander infection.

Methods

A large, retrospective, single-institution observational study was carried out over a 10-year period. The study enrolled consecutive patients who had undergone tissue expansion for scar reconstruction. Demographics, etiological data, expander-related characteristics and postoperative infection were assessed. Univariate and multivariate logistic regression analysis were performed to identify risk factors for expander infection. In addition, we conducted a sensitivity analysis for treatment failure caused by infection as an outcome.

Results

A total of 2374 expanders and 148 cases of expander infection were assessed. Treatment failure caused by infection occurred in 14 expanders. Multivariate logistic regression analysis identified that disease duration of ≤1 year (odds ratio (OR), 2.07; p < 0.001), larger volume of expander (200–400 ml vs <200 ml; OR, 1.74; p = 0.032; >400 ml vs <200 ml; OR, 1.76; p = 0.049), limb location (OR, 2.22; p = 0.023) and hematoma evacuation (OR, 2.17; p = 0.049) were associated with a high likelihood of expander infection. Disease duration of ≤1 year (OR, 3.88; p = 0.015) and hematoma evacuation (OR, 10.35; p = 0.001) were so related to high risk of treatment failure.

Conclusions

The rate of expander infection in patients undergoing scar reconstruction was 6.2%. Disease duration of <1 year, expander volume of >200 ml, limb location and postoperative hematoma evacuation were independent risk factors for expander infection.

Invited Discussion on: Management of Expander and Implant Associated Infections in Breast Reconstruction

The author presents an objective review on "Management of Expander and Implant Associated Infections in Breast Reconstruction," discussing different points related to this subject, such as infection definition, identification of risk factors, related microorganisms, surgical techniques, preventive measures, antibiotic prophylaxis and therapy. Flaws in methodologies are identified and points of discrepancy in data and treatment results from previously published studies are pointed out, with discussion of possible causes for these inconsistencies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

The use of surgical site drains in breast reconstruction: A systematic review

BACKGROUND

Use of drains has been advocated in order to prevent seroma and hematoma; however, specific recommendations vary widely. The goal is to perform a systematic analysis of published literature on the use of drains for breast reconstruction.

METHODS

The literature search was performed according to the PRISMA guidelines. The search included the Cochrane Library, Embase, and Pubmed databases using the terms "breast reconstruction" and "breast flap" combined with "drain", "seroma," and "seroma prevention". The references were appraised in two rounds, by two independent reviewers; studies were included/excluded based on relevance of title and subsequently by the content of their abstracts/manuscripts. Outcomes regarding seroma, infection rate, length of stay (LOS), drainage, reconstruction type and complications were analyzed.

RESULTS

Of 2252 studies identified via search, 64 were relevant and 21 met inclusion criteria. Most of the study designs were case series or retrospective cohort studies (Level of Evidence III or IV), with the exception of one prospective randomized-controlled trial. Seroma rate was given in 18 studies, infection rate in 11, and criteria for drain removal in 19. Reoperation rate was available in 7 and LOS in 18 studies. The majority of studies (13) agreed to remove the drain when the output was less than 30 ml/24 h. Drain output was reported in 11, and 20 reported drain type used.

CONCLUSION

There is sparse literature available with which to make evidence-based guidelines. A standardized guideline for reporting drain use is crucial to providing a better understanding of complications in breast reconstruction related to surgical drains.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tissue expanders; review of indications, results and outcome during 15 years' experience

BACKGROUND

Tissue expanders (TE) are frequently used worldwide. In this study we surveyed outcome of our patients retrospectively during 15 years.

MATERIALS AND METHODS

We had 1105 patients for whom 3059 TEs have been used. Demographic data, age, sex, indications, type of tissue expander devices, volume of devices, site of scar and site TE insertion, our technique for tissue expander insertion and flap design, complications and outcome were gathered. A complete and through technical points and tips will be discussed.

RESULTS

In 91% of patients overexpansion was done. (Expansion ratio=2.1-4.5). Re-expansion has been done in about 12% of patients. Complications were perforation of skin of pocket (11%) or exposure, infection (6%), dehiscence of the wound (1.5%), perforation of the port or disconnection of the tubes (2.1%), expansion of the scar itself (1%), saggy flap (3%), dog ear (5%), lack of adhesions of flap to its new site (4%).

OUTCOME

In 93% of the patients we could totally remove the scar. Around 9.1% of our patients had two sessions of expansion in the same area and 2.9% had three sessions of expansion. 51% of our patients were highly satisfied and 42% were satisfied of the results of expansion.

CONCLUSION

Our patients were satisfied with the results. In 12% cases we have done re-expansion. Re-expansion is possible as long as you have enough thickness of dermis in the skin. More than 50% of our patients were optimistic for 2nd or 3rd session of re-expansion.

Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry

Background

The American Society of Breast Surgeons (ASBrS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non-randomized, IRB approved, multi-institutional registry. The purpose of this Registry is to provide a large, prospective, non-randomized database of patient characteristics, tumor characteristics, surgical technique, and outcome (both aesthetic and oncologic) of the nipple sparing mastectomy (NSM).

Methods

Data is entered into the ASBrS NSMR, housed within the Mastery of Surgery Program, after patients consent to participation. Each investigator routinely offers NSM in their practice has obtained IRB approval and completed forms of agreement to participate in the ASBrS NSMR.

Results

This data set represents a total of 1,935 NSMs performed on 1,170 patients by 98 investigators from 70 institutions/sites. Of the 1,935 NSMs: 833 were performed for an indication of cancer [594 invasive carcinoma and 239 for ductal carcinoma in situ (DCIS)] and 1,102 were prophylactic. Of the 1,170 total patients, 352 underwent a unilateral and 818 underwent a bilateral NSM. Recurrence at a mean follow-up of 31 months/median follow-up of 27 months, with a range of 9.7 to 58.3 months since surgery was 1.4% with no recurrences at the nipple or nipple areola complex (NAC). Cancer occurrence (0.3%) also did not involve the nipple/NAC. Overall patient satisfaction of excellent/good: 94.9% and overall cosmesis (surgeon rated) of excellent/good was 96.4%. Overall infection rates included flap infection of 4.4%, NAC complication rate of 4.5% (defined as necrosis/other or ischemia/epidermolysis requiring surgery), and a 10% rate of NAC epidermolysis with full recovery.

Conclusions

NSMs were performed on breasts with a variety of sizes and degrees of ptosis, via multiple incisions, dissection and reconstruction techniques with low complication rates and high patient satisfaction and surgeon rated cosmesis.

Late Surgical-Site Infection in Immediate Implant-Based Breast Reconstruction

BACKGROUND

Surgical-site infection causes devastating reconstructive failure in implant-based breast reconstructions. Large national database studies offer insights into complication rates, but only capture outcomes within 30 days postoperatively. This study evaluates both early and late surgical-site infection in immediate implant-based reconstruction and identifies predictors.

METHODS

As part of the Mastectomy Reconstruction Outcomes Consortium Study, 1662 implant-based breast reconstructions in 1024 patients were evaluated for early versus late surgical-site infection. Early surgical-site infection was defined as infection occurring within 30 days postoperatively; late surgical-site infection was defined as infection occurring 31 days to 1 year postoperatively. Minor infection required oral antibiotics only, and major infection required hospitalization and/or surgical treatment. Direct-to-implant patients had 1-year follow-up, and tissue expander patients had 1-year post-exchange follow-up.

RESULTS

Among 1491 tissue expander and 171 direct-to-implant reconstructions, overall surgical-site infection rate for tissue expander was 5.7 percent (85 of 1491) after first-stage, 2.5 percent (31 of 1266) after second-stage, and 9.9 percent (17 of 171) for direct-to-implant reconstruction. Over 47 to 71 percent of surgical-site infection complications were late surgical-site infection. Multivariate analysis identified radiotherapy and increasing body mass index as significant predictors of late surgical-site infection. No significant difference between the direct-to-implant and tissue expander groups in the occurrence of early, late, or overall surgical-site infection was found.

CONCLUSIONS

The majority of surgical-site infection complications in immediate implant-based breast reconstructions occur more than 30 days after both first-stage and second-stage procedures. Radiotherapy and obesity are significantly associated with late-onset surgical-site infection. Current studies limited to early complications do not present a complete assessment of infection associated with implant-based breast reconstructions or their long-term clinical outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

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.