Reducing implant loss rates in immediate breast reconstructions

Case report of the combination of a TRAM flap, lipofilling, and 3-D tattooing after failed implant-based reconstruction: improving aesthetic results

We present a complex case of a patient diagnosed with bilateral breast cancer. The patient initially underwent bilateral skin-sparing mastectomy and immediate subpectoral implant-base breast reconstruction. She had an uncomplicated postoperative recovery. However, three months later, she developed a severe and persistent local infection during adjuvant chemotherapy, resulting in the loss of the breast implants and the formation of massive deforming scars in the chest area. To address this, the patient underwent a series of reconstructive procedures. Lipofilling was used on the chest wall to improve skin quality, followed by a late bilateral transverse rectus abdominis myocutaneous flap for breast reconstruction. Additionally, the final aesthetic result was enhanced by applying a 3-D tattoo. This case highlights the use of a sequence of reconstructive procedures as a feasible alternative to manage complex and extensive scars after failure of primary breast reconstruction.

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review

BACKGROUND

There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives.

METHODS

English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team.

RESULTS

We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria.

CONCLUSIONS

Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.

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.

Implant Loss and Associated Risk Factors following Implant-based Breast Reconstructions

Implant loss is the most severe complication of implant-based breast reconstructions. This study aimed to evaluate the incidence of implant loss and other complications, identify associated risk factors, and create a risk model for implant loss.

Methods

This was a retrospective cohort study of all patients who underwent a mastectomy, followed by either a two-stage or a direct-to-implant breast reconstruction. Patient variables, operative characteristics, and postoperative complications were obtained from the patient records. A multivariate mixed-effects logistic regression model was used to create a risk model for implant loss.

Results

A total of 297 implant-based breast reconstructions were evaluated. Overall, the incidence of implant loss was 11.8%. Six risk factors were significantly associated with implant loss: obesity, a bra cup size larger than C, active smoking status, a nipple-preserving procedure, a direct-to-implant reconstruction, and a lower surgeon's volume. A risk model for implant loss was created, showing a predicted risk of 8.4%-13% in the presence of one risk factor, 21.9%-32.5% in the presence of two, 47.5%-59.3% in the presence of three, and over 78.2% in the presence of four risk factors.

Conclusions

The incidence of implant loss in this study was 11.8%. Six associated significant risk factors were identified. Our risk model for implant loss revealed that the predicted risk increased over 78.2% when four risk factors were present. This risk model can be used to better inform patients and decrease the risk of implant loss by optimizing surgery using personalized therapy.

The American College of Surgeons National Quality Improvement Program Incompletely Captures Implant-Based Breast Reconstruction Complications

BACKGROUND

Implant-based breast reconstruction (IBR) accounts for 70% of postmastectomy reconstructions in the United States. Improving the quality of surgical care in IBR patients through accurate measurements of outcomes is necessary. The purpose of this study is to compare the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from our institution to our complete institutional health records database.

METHODS

Data were collected and recorded for all patients undergoing IBR at our institution from 2015 to 2017. The data were completely identified and compared with our institutional NSQIP database for demographics and complications.

RESULTS

The electronic health records data search identified 768 IBR patients in 3 years and NSQIP reported on 229 (30%) patients. Demographics were reported similarly among the 2 databases. Rates of tissue expander/implant infections (5.9% vs 1.8%; P = 0.003) and wound dehiscence (3.5% vs 0.4%; P = 0.003) were not reported similarly between our database and NSQIP. However, the rates of hematoma (2.7% vs 1.8%) and skin flap necrosis (2.5% vs 1.8%) were comparable between the two databases. In our database, 43% of all complications presented after 30 days of surgery, beyond NSQIP's capture period.

CONCLUSIONS

Databases built on partial sampling, such as the NSQIP, may be useful for demographic analyses, but fall short of providing data for complications after IBR, such as infections and wound dehiscence. These results highlight the utility and importance of complete databases. National comparisons of clinical outcomes for IBR should be interpreted with caution when using partial databases.

Pectoral Fascia Preservation in Oncological Mastectomy to Reduce Complications and Improve Reconstructions: A Systematic Review

Excision of the pectoral fascia (PF) is routinely performed in oncological mastectomies. Preservation of the PF may, however, decrease postoperative complication rates for bleeding, infections, and seroma. It may also improve reconstructive outcomes by better prosthesis coverage, thereby reducing implant extrusion rates and improving cosmetic outcomes.

Acellular dermal matrices as an adjunct to implant breast reconstruction: Analysis of outcomes and complications

PURPOSE

Acellular dermal matrices (ADM) are increasingly used in implant-based breast reconstruction (IBR). Uncertainty remains with regard to their efficacy and complications. The aim of this study was to evaluate the outcomes and complication rates associated with the use of ADMs in IBR.

METHODS

Retrospective cohort study of patients undergoing ADM-assisted IBR between 2008 and 2013. Cases were identified from a prospectively collected database. Simple descriptive statistics and logistic regression analysis were performed.

RESULTS

A total of 110 patients (175 mastectomies) were included in the analysis. The median age was 46 (19-75) years and the median BMI was 22.2 (16.2-41.5). Seventy nine mastectomies were performed for therapeutic purposes. The median mastectomy weight was 244 (185-335) gr. The majority of reconstructions were performed with fixed volume (n = 115, 66%) or permanent expandable implants (n = 53, 30%) as one-stage procedures. Forty mastectomies were associated with at least one complication. The infection rate was 2.3% (n = 4). Post-operative haematoma developed in 5 cases (2.9%), but only 2 required surgical interventions. Three mastectomies were complicated by nipple necrosis (3.6%), 3 with skin necrosis (1.7%) and 9 with wound dehiscence (5.1%). The capsule formation rate was 2.3% (n = 4). Reconstruction failure with implant loss occurred in 3 cases (1.7%).

CONCLUSIONS

The complication rates following ADM-assisted IBR can be very low with appropriate patient selection and meticulous surgical technique. This supports the safety of using ADM in carefully selected patients. Further research is warranted to assess the health economics of ADM use in IBR.

Surgical Site Infection after Breast Surgery: A Retrospective Analysis of 5-Year Postoperative Data from a Single Center in Poland

Background and Objectives: Surgical site infection (SSI) is a significant complication of non-reconstructive and reconstructive breast surgery. This study aimed to assess SSI after breast surgery over five years in a single center in Poland. The microorganisms responsible for SSI and their antibiotic susceptibilities were determined. Materials and Methods: Data from 2129 patients acquired over five years postoperatively by the Department of Surgical Oncology, Medical University of Gdansk in Poland were analyzed. Results: SSI was diagnosed in 132 patients (6.2%) and was an early infection in most cases (65.2%). The incidence of SSI was highest in patients who underwent subcutaneous amputation with simultaneous reconstruction using an artificial prosthesis (14.6%), and breast reconstruction via the transverse rectus abdominis muscle (TRAM) flap method (14.3%). Gram-positive bacteria were responsible for SSI in most cases (72.1%), and these were mainly Staphylococcus strains (53.6%). These strains were 100% susceptible to all beta-lactam antibiotics (except penicillin) but were less susceptible to macrolides and lincosamides. Conclusions: SSI is a serious problem, and attention should be focused on its prevention. Reconstruction using an artificial prosthesis or via the TRAM flap method is connected to increased SSI incidence. Further studies are required to prevent SSI following breast surgery.

Defining Quality Indicators for Breast Device Surgery: Using Registries for Global Benchmarking

Breast device registries monitor devices encompassing breast implants, tissue expanders and dermal matrices, and the quality of care and patient outcomes for breast device surgery. Defining a standard set of quality indicators and risk adjustment factors will enable consistency and adjustment for case-mix in benchmarking quality of care across breast implant registries. This study aimed to develop a set of quality indicators to enable assessment and reporting of quality of care for breast device surgery which can be applied globally.

METHODS

A scoping literature review was undertaken, and potential quality indicators were identified. Consensus on the final list of quality indicators was obtained using a modified Delphi approach. This process involved a series of online surveys, and teleconferences over 6 months. The Delphi panel included participants from various countries and representation from surgical specialty groups including breast and general surgeons, plastic and reconstructive surgeons, cosmetic surgeons, a breast-care nurse, a consumer, a devices regulator (Therapeutic Goods Administration), and a biostatistician. A total of 12 candidate indicators were proposed: Intraoperative antibiotic wash, intraoperative antiseptic wash, preoperative antibiotics, nipple shields, surgical plane, volume of implant, funnels, immediate versus delayed reconstruction, time to revision, reoperation due to complications, patient satisfaction, and volume of activity.

RESULTS

Three of the 12 proposed indicators were endorsed by the panel: preoperative intravenous antibiotics, reoperation due to complication, and patient reported outcome measures.

CONCLUSION

The 3 endorsed quality indicator measures will enable breast device registries to standardize benchmarking of care internationally for patients undergoing breast device surgery.

Antimicrobial efficacy of copper-doped titanium surfaces for dental implants

The aim of this in vitro study was to quantify the antibacterial effect of a copper-deposited titanium surface as a model for dental implants on the peri-implantitis-associated strain Porphyromonas gingivalis (DSM 20709). A spark-assisted anodization method in a combined deposition-anodization process was applied to deposit copper on discs made of titanium. This method allows the deposition of different concentrations of copper on the surface by varying the process time. Conventional culturing was used to investigate the adhesion of P. gingivalis onto the discs over 2, 4, and 6 h as well as to study the antibacterial effect of copper released in solution. The viability of the bacterial cells is strongly inhibited on copper-deposited discs and reaches a CFU reduction of 3 log-units after 6 h in comparison to the reference. The copper released in solution causes a reduction of 4 log-units after a 6 h incubation time. With a 6 h incubation time, the CFU count decreases with increasing copper concentrations on the disc (by 2% for the 1.3 µg/disc; 32% for the 5.6 µg/disc; and 34% for the 9.5 µg/disc). However, at a higher copper concentration of 17.7 µg/disc, after 6 h, the decrease in the CFU count is less pronounced than that observed in solution, where a further decrease is observed. In conclusion, copper-functionalized titanium significantly reduces the survival of adhered bacteria and decreases the viable bacterial count in the environment surrounding the titanium. Thus, the area surrounding implants is being protected by copper released from the surface, forming a "safe zone" for improved implant healing.

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire

Introduction

The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.

Methods

A questionnaire investigating local practice and service provision of IBBR developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Summary data for each survey item were calculated and variation between centres and overall provision of care examined.

Results

81 units within 79 NHS-hospitals completed the questionnaire. Units offered a range of reconstructive techniques, with IBBR accounting for 70% (IQR:50–80%) of participating units' immediate procedures. Units on average were staffed by 2.5 breast surgeons (IQR:2.0–3.0) and 2.0 plastic surgeons (IQR:1.0–3.0) performing 35 IBBR cases per year (IQR:20-50). Variation was demonstrated in the provision of novel different techniques for IBBR especially the use of biological (n = 62) and synthetic (n = 25) meshes and in patient selection for these procedures.

Conclusions

The iBRA-NPQ has demonstrated marked variation in the provision and practice of IBBR in the UK. The prospective audit phase of the iBRA study will determine the safety and effectiveness of different approaches to IBBR and allow evidence-based best practice to be explored.

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Implant breast reconstruction (IBBR) and the range of techniques is poorly evidence based.

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We aimed to explore the current practice of IBBR in the UK to inform the design of a future definitive study.

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Significant variation was demonstrated in the availability of techniques and patient selection for IBBR.

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There is a need for well-designed studies to establish best practice and improve outcomes for patients considering IBBR.