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Xie Y, Hu X, Du Z, Liang F, Lv Q, Li B. Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction. Aesthetic Plast Surg 2024; 48:266-272. [PMID: 37605028 DOI: 10.1007/s00266-023-03525-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prosthetic infection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction. METHODS A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes. RESULTS A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy. CONCLUSION Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective. 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 .
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Affiliation(s)
- Yanyan Xie
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoxia Hu
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenggui Du
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Faqing Liang
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Lv
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China.
- Breast Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Bo Li
- Department of General Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, China.
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Awadeen A, Fareed M, Elameen AM. The Impact of Botulinum Toxin Injection on the Outcomes of Breast Surgeries: A Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2023; 47:1771-1784. [PMID: 37464214 PMCID: PMC10582146 DOI: 10.1007/s00266-023-03466-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/11/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Breast surgeries aim to restore the natural appearance of the breasts with acceptable functional and cosmetic outcomes. However, these surgical procedures may be associated with considerable adverse events. The present systematic review and meta-analysis was designed to reveal the functional and aesthetic outcomes of botulinum toxins (BTX) injection in patients subjected to breast surgeries. METHODS A literature review was performed up to 21 September 2022. All clinical studies included patients older than 18 years old and treated with BTX injection for breast surgeries were included. RESULTS The present study included 12 articles, encompassing 496 patients. The average dosage of BTX injection ranged from 20 to 100 units. Injecting BTX significantly reduced the mean post-operative opioid analgesics usage (SMD -1.577; 95% -2.087, -1.067; P < 0.001) and the risk of severe animation deformity (RR 12.37; 95% 1.76, 86.66; P = 0.01). There was a statistically significant higher mean expansion volume per visit in the BTX injection group (SMD 1.166; 95% 0.313, 2.018; P = 0.007). There was no statistically significant impact of BTX injection on the risk of surgical site infection (RR 0.59; 95% 0.15, 2.34; P = 0.45) and seroma (RR 0.51; 95% 0.03, 10.15; P = 0.66). CONCLUSIONS The present study revealed the potential benefits of BTX injection in breast surgeries. This included reduced post-operative analgesics, as well as the risk of severe animation deformity. This was accomplished with increased expansion volume per visit and a similar risk of BTX injection-related complications. 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 .
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Affiliation(s)
- Abdelrahman Awadeen
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine (Boys), Al-Azhar University, Al Mokhaym Al Daem, Gameat Al Azhar, Nasr City, Cairo, Egypt.
| | - Mohamed Fareed
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine (Boys), Al-Azhar University, Al Mokhaym Al Daem, Gameat Al Azhar, Nasr City, Cairo, Egypt
| | - Ali Mohamed Elameen
- Department of Plastic and Reconstructive Surgery, El-Sahel Teaching Hospital, Cairo, Egypt
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Ahmed S, Lee JTC, Roth D, Sinha M, Fisher C, Fan B, Imeokparia F, Ludwig K, Lester ME, Hassanein AH. Prophylactic Absorbable Antibiotic Beads for High-risk, Implant-based Prepectoral Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5353. [PMID: 37850203 PMCID: PMC10578659 DOI: 10.1097/gox.0000000000005353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/06/2023] [Indexed: 10/19/2023]
Abstract
Infections are problematic in postmastectomy implant-based reconstruction with infection rates as high as 30%. Strategies to reduce the risk of infection have demonstrated various efficacies. A prolonged course of systemic, oral antibiotics has not shown evidence-based benefit. Although absorbable antibiotic beads have been described for orthopedic procedures and pressure wounds, their use has not been well studied during breast reconstruction, particularly for prepectoral implant placement. The purpose of this study was to evaluate the selective use of prophylactic absorbable calcium sulfate antibiotic beads during high-risk implant-based, prepectoral breast reconstruction after mastectomy. Patients who underwent implant-based, prepectoral breast reconstruction between 2019 and 2022 were reviewed. Groups were divided into those who received antibiotic beads and those who did not. Outcome variables included postoperative infection at 90 days. A total of 148 patients (256 implants) were included: 15 patients (31 implants) who received biodegradable antibiotic beads and 133 patients (225 implants) in the control group. Patients who received antibiotic beads were more likely to have a history of infection (66.7%) compared with the control group (0%) (P < 0.01). Surgical site infection occurred in 3.2% of implants in the antibiotic bead group compared with 7.6%, but this did not reach statistical significance. The incidence of infection in high-risk patients who have absorbable antibiotic beads placed during the time of reconstruction seems to be normalized to the control group in this pilot study. We present a novel use of prophylactic absorbable antibiotic beads in prepectoral breast implant reconstruction.
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Affiliation(s)
- Shahnur Ahmed
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Jason T. C. Lee
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Dylan Roth
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Mithun Sinha
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Carla Fisher
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Betty Fan
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Folasade Imeokparia
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Kandice Ludwig
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Mary E. Lester
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Aladdin H. Hassanein
- From Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Ind
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Langdell HC, Sergesketter AR, Biswas S, Morris M, Zhang GX, Atia A, Phillips BT. Consequences and Predictors of Prolonged Tissue Expander Duration in Breast Reconstruction. J Reconstr Microsurg 2023; 39:655-663. [PMID: 36808614 DOI: 10.1055/a-2039-1305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Tissue expanders (TEs) are temporary devices used in breast reconstruction, which are generally removed within 1 year. There is a paucity of data regarding the potential consequences when TEs have longer indwelling times. Thus, we aim to determine whether prolonged TE implantation length is associated with TE-related complications. METHODS This is a single-center retrospective review of patients who underwent TE placement for breast reconstruction from 2015 to 2021. Complications were compared between patients who had a TE for >1 year and <1 year. Univariate and multivariate regressions were used to evaluate predictors of TE complications. RESULTS A total of 582 patients underwent TE placement and 12.2% had the expander for >1 year. Adjuvant chemoradiation, body mass index (BMI), overall stage, and diabetes predicted the duration of TE placement (p ≤ 0.006). Rate of return to the operating room was higher in patients who had TEs in place >1 year (22.5 vs 6.1%, p < 0.001). On multivariate regression, prolonged TE duration predicted an infection requiring antibiotics, readmission, and reoperation (p < 0.001). Reasons for longer indwelling times included need for additional chemoradiation (79.4%), TE infections (12.7%), and requesting a break from surgery (6.3%). CONCLUSION Indwelling TEs for >1 year are associated with higher rates of infection, readmission, and reoperation even when controlling for adjuvant chemoradiation. Patients with diabetes, a higher BMI, advanced cancer stage, and those requiring adjuvant chemoradiation should be advised they may require a TE for a longer time interval prior to final reconstruction.
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Affiliation(s)
- Hannah C Langdell
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
| | - Amanda R Sergesketter
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sonali Biswas
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
| | - Miranda Morris
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
| | - Gloria X Zhang
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew Atia
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brett T Phillips
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
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Use of Antibiotic-impregnated Polymethylmethacrylate (PMMA) Plates for Prevention of Periprosthetic Infection in Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e4764. [PMID: 36776590 PMCID: PMC9911200 DOI: 10.1097/gox.0000000000004764] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 01/19/2023]
Abstract
Periprosthetic infections remain a major challenge for breast reconstruction. Local antibiotic delivery systems, such as antibiotic beads and spacers, have been widely used within other surgical fields, but their use within plastic surgery remains scarce. In this study, we demonstrate the use of antibiotic-impregnated polymethylmethacrylate (PMMA) plates for infection prophylaxis in tissue expander (TE)-based breast reconstruction. Methods A retrospective review of patients who underwent immediate breast reconstruction with prepectoral TEs over the span of 5 years performed by two surgeons was completed, revealing a total of 447 patients. Data pertaining to patient demographics, operative details, and postoperative outcomes were recorded. Fifty patients underwent TE reconstruction with the addition of a PMMA plate (Stryker, Kalamazoo, Michigan) impregnated with tobramycin and vancomycin. Antibiotic plates were removed at the time of TE-to-implant exchange. Patient-matching analysis was performed using the 397 patients without PMMA plates to generate a 50-patient nonintervention cohort for statistical analysis. Results The intervention cohort (n = 50) and 1:1 patient-matched nonintervention cohort (n = 50) demonstrated no statistically significant differences in patient demographics or operative characteristics other than PMMA plate placement. The rate of operative periprosthetic infection was 4% in the intervention group and 14% in the nonintervention group (P = 0.047). The rate of TE explantation was also reduced in the intervention group (6% versus 18%; P = 0.036). Follow-up averaged 9.1 and 8.9 months for the intervention and nonintervention groups, respectively (P = 0.255). Conclusion Local antibiotic delivery using antibiotic-impregnated PMMA plates can be safely and effectively used for infection prevention with TE-based breast reconstruction.
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Yi KH, Lee JH, Kim HM, Kim HJ. The botulinum neurotoxin for pain control after breast reconstruction: neural distribution of the pectoralis major muscle. Reg Anesth Pain Med 2022; 47:322-326. [PMID: 35039438 DOI: 10.1136/rapm-2021-102653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 01/02/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The use of the botulinum neurotoxin injection is a growing area of research and clinical activity, with a focus on its role in facilitating postoperative pain management after reconstructive breast surgery. The study aimed to find out the standard injection points for botulinum neurotoxin injection by revealing the intramuscular nerve arborization of the pectoralis major. METHODS Sihler's technique was conducted on the pectoralis major muscles (16 cadaveric specimens). The intramuscular nerve arborization was documented relative to the inferior border of the clavicle bone and lateral border of the sternum. RESULTS After the staining, the pectoralis major was divided into fifths transversely from the inferior border of the clavicle and vertically into fifths from the lateral border of the sternum. Intramuscular nerve arborization of the pectoralis major muscle was the largest in the middle sections of the muscle belly. DISCUSSION The results indicate that botulinum neurotoxin should be applied to the pectoralis major in certain regions. The regions of major arborization are optimal as the most effective and most reliable points for injecting botulinum neurotoxin.
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Affiliation(s)
- Kyu-Ho Yi
- Division of COVID-19, Wonju Public Health Center, Wonju, Korea
| | - Ji-Hyun Lee
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, Korea
| | | | - Hee-Jin Kim
- Yonsei University Medical Center, Seodaemun-gu, Korea
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Lisa A, Belgiovine C, Maione L, Rimondo A, Battistini A, Agnelli B, Murolo M, Galtelli L, Monari M, Klinger M, Vinci V. Study of Inflammatory and Infection Markers in Periprosthetic Fluid: Correlation with Blood Analysis in Retrospective and Prospective Studies. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6650846. [PMID: 33791369 PMCID: PMC7997767 DOI: 10.1155/2021/6650846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/25/2021] [Accepted: 03/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical site infection represents the most severe complication in prosthetic breast reconstruction. Risk profiling represents a useful tool for both clinicians and patients. MATERIALS AND METHODS In our hospital, 534 breast reconstructions with tissue expander implants, in 500 patients, were performed. Several clinical variables were collected. In our study, we evaluated the different inflammatory markers present in the periprosthetic fluid and we compared them with the ones present in plasma. RESULTS The surgical site infection rate resulted to be 10.5%, and reconstruction failed in 4.5% of the cases. The hazard ratio for complications was 2.3 in women over 60 (CI: 1.3-4.07; p = 0.004), 2.57 in patients with expander volume ≥ 500 cc (CI: 1.51-4.38; p < 0.001), 2.14 in patients submitted to previous radiotherapy (CI: 1.05-4.36; p < 0.037), and 1.05 in prolonged drain use (CI: 1.03-1.07; p < 0.001). 25-OH, PCT, and total protein were less concentrated, and ferritin and LDH were more concentrated in the periprosthetic fluid than in plasma (p < 0.001). CRP (p = 0.190) and β-2 microglobulin (p = 0.344) did not change in the two fluids analyzed. PCT initial value is higher in patients who underwent radiotherapy, and it could be related to the higher rate of their postoperative complications. Patients with a tissue expander with a volume ≥ 500 cc show an increasing trend for CRP in time (p = 0.009). CONCLUSIONS Several risk factors (prolonged time of drains, age older than 60 years, and radiotherapy) have been confirmed by our study. The study of markers in the periprosthetic fluid with respect to their study in plasma could point toward earlier infection detection and support early management.
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Affiliation(s)
- Andrea Lisa
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Cristina Belgiovine
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
- Scuola di Specializzazione in Microbiologia e Virologia, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Luca Maione
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
- University of Milan, Reconstructive and Aesthetic Plastic Surgery School-Clinica San Carlo-Plastic Surgery Unit-Paderno Dugnano (Milan), Italy
| | - Andrea Rimondo
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Andrea Battistini
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Benedetta Agnelli
- Humanitas University Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Matteo Murolo
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Leonardo Galtelli
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
| | - Marta Monari
- Clinical Investigation Laboratory, Humanitas Clinical and Research Center, Via Alessandro Manzoni 56 20089 Rozzano Milano, Italy
| | - Marco Klinger
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Humanitas Clinical and Research Hospital, Reconstructive and Aesthetic Plastic Surgery School, University of Milan, Via Manzoni 56, Rozzano, Milan 20090, Italy
| | - Valeriano Vinci
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089 Rozzano Milan, Italy
- Humanitas University Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
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Management of Expander- and Implant-Associated Infections in Breast Reconstruction. Aesthetic Plast Surg 2020; 44:2075-2082. [PMID: 32840671 DOI: 10.1007/s00266-020-01923-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Periprosthetic infection remains the most common complication after implant-based breast reconstruction. Objectives of the study were to (1) describe our clinical approach and treatment protocol for managing patients with suspected periprosthetic infection, (2) identify the microorganisms causing periprosthetic infections at our institute, and (3) report on outcomes of implant salvage versus explantation. METHODS A retrospective chart review of patients who were treated with parenteral antibiotics for periprosthetic infection was carried out. Patient characteristics, clinical and laboratory findings, outcomes, treatment modalities and complications were extracted from electronic medical records. Data were compared between patients whose implants were salvaged versus explanted. RESULTS Fifty-nine patients with 67 tissue expander (TE)/implants underwent parenteral antibiotic treatment for suspected infection. Thirty-three (49%) of the TE/implants were salvaged. Mean follow-up was 14.3 months. The most commonly cultured organisms were P. aeruginosa followed by S. epidermidis. All suspected infections were treated with broad spectrum parenteral antibiotics with MRSA coverage. The most common combination was daptomycin 6 mg/kg combined with Zosyn 4.5 g. Explantations were significantly more common in patients with history of chemotherapy (p = 0.03), hypertension (p = 0.04) and those who underwent therapeutic mastectomy (p = 0.04). CONCLUSION Risk factors for explantation due to postoperative periprosthetic infections following TE/implant-based breast reconstruction include chemotherapy, hypertension and therapeutic mastectomy. Prompt diagnosis and effective treatment of periprosthetic infection, particularly in these high-risk patients, are imperative to salvage the breast reconstruction. Gram-negative bacteria are increasingly found in breast implant infections and should be covered when employing empiric antibiotherapy. 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 .
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Lohmeyer JA, Jakob VL, Keck M, Wittig K. Antibiotic treatment and prophylaxis of periprosthetic infections: Evaluation of 666 consecutive breast implant removals. J Plast Reconstr Aesthet Surg 2020; 74:1486-1494. [PMID: 33308989 DOI: 10.1016/j.bjps.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/28/2020] [Accepted: 11/12/2020] [Indexed: 10/23/2022]
Abstract
Periprosthetic infections are feared complications in esthetic and reconstructive breast surgery. The purpose of our study is to evaluate our institution's specific culture data and to identify most common organisms and suitable antibiotics for prophylaxis and first-line treatment. We evaluated all patients with a change or removal of breast implants from 01.01.2012 to 31.12.2017 retrospectively. Based on the medical records, the surgical indications were identified and specifically analyzed for signs of infection, reasons for primary and secondary surgery, and all available microbiological data of these interventions. A total of 666 implant removals or exchanges were performed in 431 patients. Microbiological smears were gathered from 291 patients (449 implants). Bacteria were cultured from 63 implants (56 patients). In six additional patients (ten implants), a periprosthetic infection was seen, without bacteria detection. Advanced capsular contracture correlated with a higher proportion of positive swabs (p<0.05). In 11.5% of smears, bacterial contamination was found despite absence of clinical signs of infection. Coagulase-negative staphylococci were the dominant pathogen in clinical inapparent infections, while Staphylococcus aureus was when there was clinical evidence of infection. All pathogens were sensitive to vancomycin. In the majority of cases, bacterial contamination was an incidental finding, which was more common in the presence of advanced capsular contracture. In our institution, cefuroxime and amoxicillin/clavulanic acid have been proven to be reasonable choices for prevention and treatment of periprosthetic infections. In the treatment of fulminant infections and for the prophylaxis during implant replacement due to advanced capsular contracture, vancomycin became our first choice.
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Affiliation(s)
- J A Lohmeyer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, Hohe Weide 17, 20259 Hamburg, Germany; Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany.
| | - V L Jakob
- Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, Hohe Weide 17, 20259 Hamburg, Germany
| | - M Keck
- Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, Hohe Weide 17, 20259 Hamburg, Germany; Clinic of Plastic Surgery, Hand Surgery, Burn Unit, University Hospital of Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - K Wittig
- Department of Plastic, Reconstructive and Aesthetic Surgery, Agaplesion Diakonieklinikum Hamburg, Hohe Weide 17, 20259 Hamburg, Germany
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10
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Cuomo R. Submuscular and Pre-Pectoral ADM Assisted Immediate Breast Reconstruction: A Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E256. [PMID: 32466619 PMCID: PMC7353845 DOI: 10.3390/medicina56060256] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 12/13/2022]
Abstract
Background and objectives: Breast cancer treatment has deeply changed in the last fifty years. Acellular dermal matrices (ADMs) were introduced for breast reconstruction, with encouraging results, but with conflicting reports too. The present paper aims to summarize the current data on breast reconstruction using acellular dermal matrices. Materials and Methods: We reviewed the literature regarding the use of ADM-assisted implant-based breast reconstruction. Results: The main techniques were analyzed and described. Conclusions: Several authors have recently reported positive results. Nevertheless, an increased complications' rate has been reported by other authors. Higher cost compared to not-ADM-assisted breast reconstruction is another concern.
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Affiliation(s)
- Roberto Cuomo
- Santa Maria Alle Scotte Hospital, Plastic and Reconstructive Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Mario Bracci Street, 53100 Siena, Italy
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Are 30-Day Outcomes Enough? Late Infectious Readmissions following Prosthetic-Based Breast Reconstruction. Plast Reconstr Surg 2020; 144:360e-368e. [PMID: 31461001 DOI: 10.1097/prs.0000000000005903] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical-site infection is a major concern in prosthetic-based breast reconstruction. Thirty-day postoperative readmission rates are a common quality metric, but little is known about readmission rates for later infections. METHODS Using the 2013 to 2014 Nationwide Readmissions Database, the authors identified breast cancer patients undergoing breast reconstruction with implants and tissue expanders who had an infectious readmission. The authors used univariate and multivariate logistic regression models to identify predictors of infectious readmission and explantation within the early (0 to 30 days) and late (31 to 90 days) postoperative periods. RESULTS In the weighted sample, the authors identified 18,338 patients undergoing prosthetic-based breast reconstruction. The overall infectious readmission rate was 4.1 percent (n = 759): 49.3 percent occurred early and 50.7 percent occurred late. Of the infectious readmissions, 39.5 percent required explantation, 55.1 percent of which occurred during a late infectious readmission. Seventy-five percent of these infectious readmissions and explantations occurred within 49 days of initial surgery. Median annual household income less than $40,000 (p = 0.035), diabetes (p = 0.038), and obesity (p = 0.004) were independent predictors of infectious readmission. Diabetes (p = 0.049) and hypertension (p = 0.011) were independent predictors of early readmission. Median annual household income less than $40,000 (p = 0.049), obesity (p = 0.006), and increasing length of stay during the index procedure (p = 0.028) were independent predictors of late readmission. No statistically significant independent predictors for explantation were identified. CONCLUSIONS Traditional 30-day readmission rates are not an adequate quality metric for breast reconstruction given the number of late postoperative readmissions, many of which lead to explantation. Early and late infectious readmissions have different predictors. Interventions targeting these predictors may decrease the number of readmissions, thus reducing cost and improving quality. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Does timing of alloplastic breast reconstruction in older women impact immediate postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Breast 2019; 48:58-64. [PMID: 31526955 DOI: 10.1016/j.breast.2019.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/06/2019] [Accepted: 09/01/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Alloplastic breast reconstruction is safe in well-selected older women. The impact of timing of surgery on complication rates is unknown. This study aimed to determine the immediate (30-day) postoperative complication rates of older women who underwent immediate (IBR) and delayed breast reconstruction (DBR) with alloplastic techniques. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify women ≥70 years old with in situ or invasive breast cancer who underwent either IBR or DBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality. RESULTS A total of 2,085 older women underwent alloplastic breast reconstruction of which 90% and 10% were IBR and DBR, respectively. Both groups had similar median age, body mass index, and frequency of smoking, diabetes mellitus, and steroid use. Tumors were mainly invasive in the IBR group (83.5%) and in situ in the DBR group (83.3%). IBR had significantly longer operative times (median 154 min vs 98 min, p < 0.0001), but equal length of stay (median 3 days vs 3 days, p = 0.1). The 30-day overall morbidity (medical or surgical complication) rate was significantly higher in the IBR group (7.5% vs 1.0%, p < 0.0004). Women with IBR were significantly more likely to develop infectious complications (6% vs 1%, p = 0.002). Cardiac/transfusion, pulmonary, thromboembolic, renal, and neurological morbidity rates were equal between groups. Thirty-day mortality rates were similar across both groups (IBR: 0.05% vs DBR: 0%, p = 0.74). CONCLUSIONS While overall thirty-day postoperative complication rates in older women who undergo breast reconstruction were low, there were higher rates of infectious complications in the IBR cohort. The risks and benefits of alloplastic breast reconstruction should be discussed with older women undergoing mastectomy for breast cancer treatment.
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Angarita FA, Dossa F, Zuckerman J, McCready DR, Cil TD. Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database. Breast Cancer Res Treat 2019; 177:215-224. [PMID: 31154580 DOI: 10.1007/s10549-019-05273-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18-69 years). METHODS The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction. RESULTS Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30 days of breast surgery was rare. CONCLUSION Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.
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Affiliation(s)
- Fernando A Angarita
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jesse Zuckerman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - David R McCready
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Tulin D Cil
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. .,Department of Surgery, Women's College Hospital, Toronto, ON, Canada. .,Division of General Surgery, University Health Network, 610 University Ave, OPG- 6th Floor, Toronto, ON, M5G 2M9, Canada.
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Smits I, Beudeker N, Vos BJPR, Hendriks-Brouwer N, Schmidbauer U, Smulders YCMM, Zöphel OT, Rakhorst HA. Quality auditing in breast reconstruction using funnel plots and indicators: a semi-anonymous and practical method for your practice. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-018-1493-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Absorbable Antibiotic Beads Prophylaxis in Immediate Breast Reconstruction. Plast Reconstr Surg 2018; 141:486e-492e. [DOI: 10.1097/prs.0000000000004203] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dieterich M, Dragu A, Stachs A, Stubert J. Clinical Approaches to Breast Reconstruction: What Is the Appropriate Reconstructive Procedure for My Patient? Breast Care (Basel) 2018; 12:368-373. [PMID: 29456467 DOI: 10.1159/000484926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Breast reconstruction after breast cancer is an emotional subject for women. Consequently, the correct timing and surgical procedure for each individual woman are important. In general, heterologous or autologous reconstructive procedures are available, both having advantages and disadvantages. Breast size, patient habitus, and previous surgeries or radiation therapy need to be considered, independent of the chosen procedure. New surgical techniques, refinement of surgical procedures, and the development of supportive materials have increased the general patient collective eligible for breast reconstruction. This review highlights the different approaches to immediate breast reconstruction using autologous or heterologous techniques.
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Affiliation(s)
- Max Dieterich
- Department of Obstetrics and Gynecology, Klinikum Südstadt Rostock - Interdisciplinary Breast Center - University of Rostock, Rostock, Germany
| | - Adrian Dragu
- Department of Plastic and Hand Surgery, Carl Gustav Carus University of Dresden, Dresden, Germany
| | - Angrit Stachs
- Department of Obstetrics and Gynecology, Klinikum Südstadt Rostock - Interdisciplinary Breast Center - University of Rostock, Rostock, Germany
| | - Johannes Stubert
- Department of Obstetrics and Gynecology, Klinikum Südstadt Rostock - Interdisciplinary Breast Center - University of Rostock, Rostock, Germany
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Ozturk CN, Ozturk C, Soucise A, Platek M, Ahsan N, Lohman R, Moon W, Djohan R. Expander/Implant Removal After Breast Reconstruction: Analysis of Risk Factors and Timeline. Aesthetic Plast Surg 2018; 42:64-72. [PMID: 29270693 DOI: 10.1007/s00266-017-1031-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/31/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Removal of tissue expanders (TE) or implants is a dire consequence of breast reconstruction, and has the potential to halt the reconstructive efforts. Our goals were to characterize a cohort of patients with TE/implant removal, to perform a time-based analysis, and to review the bacteriology associated with explanted devices. MATERIALS AND METHODS Review of a prospectively maintained database was performed to identify patients who underwent TE/implant removal. Patient characteristics, surgical technique, adjuvant therapies, indications, complications, culture results were obtained. Data were analyzed according to timing of explantation. RESULTS A total of 55 TE and implants were removed in 43 patients. Reasons for explantation were infection (58%), patient request (22%), and wound-related complications (20%). The majority of explantations occurred after 30 days (62%), and after Stage I (81%). Median days to explantation was 62. Patients of older age (p = 0.01) and higher BMI (p = 0.02) were more likely to undergo explantation after Stage I. The most commonly cultured organisms were S. epidermidis (10.9%), S. aureus (10.9%) and P. aeruginosa (10.9%). Antibiotic resistance was commonly encountered for ampicillin, cefazolin, penicillin, and erythromycin. CONCLUSION Infection is the most common reason for explantation after prosthetic breast reconstruction. Patients should be carefully monitored for a prolonged period of time after Stage I, as the majority of explantations occur in this stage but beyond 30 days. For oral treatment, fluoroquinolones and trimethoprim-sulfamethoxazole and for IV treatment a combination of vancomycin or daptomycin with piperacillin-tazobactam or imipenems/carbapenems appear to be appropriate choices according to our culture results. 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 .
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Bellini E, Pesce M, Santi P, Raposio E. Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1791546. [PMID: 29376067 PMCID: PMC5742435 DOI: 10.1155/2017/1791546] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/20/2017] [Accepted: 11/19/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Breast cancer, the most common malignancy in women, comprises 18% of all female cancers. Mastectomy is an essential intervention to save lives, but it can destroy one's body image, causing both physical and psychological trauma. Reconstruction is an important step in restoring patient quality of life after the mutilating treatment. MATERIAL AND METHODS Tissue expanders and implants are now commonly used in breast reconstruction. Autologous reconstruction allows a better aesthetic result; however, many patients prefer implant reconstruction due to the shorter operation time and lack of donor site morbidity. Moreover, this reconstruction strategy is safe and can be performed in patients with multiple health problems. Tissue-expander reconstruction is conventionally performed as a two-stage procedure starting immediately after mammary gland removal. RESULTS Mastectomy is a destructive but essential intervention for women with breast cancer. Tissue expansion breast reconstruction is a safe, reliable, and efficacious procedure with considerable psychological benefits since it provides a healthy body image. CONCLUSION This article focuses on this surgical technique and how to achieve the best reconstruction possible.
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Affiliation(s)
- Elisa Bellini
- Department of Medicine and Surgery, Plastic Surgery Section, University of Parma, Parma, Italy
- Cutaneous, Mini-Invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
| | - Marianna Pesce
- Plastic Surgery Chair, Department of Surgical Sciences and Related Methodologies (DICMI), University of Genova, Genova, Italy
| | - PierLuigi Santi
- Plastic Surgery Chair, Department of Surgical Sciences and Related Methodologies (DICMI), University of Genova, Genova, Italy
| | - Edoardo Raposio
- Department of Medicine and Surgery, Plastic Surgery Section, University of Parma, Parma, Italy
- Cutaneous, Mini-Invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
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Bertozzi N, Pesce M, Santi P, Raposio E. One-Stage Immediate Breast Reconstruction: A Concise Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6486859. [PMID: 29098159 PMCID: PMC5643043 DOI: 10.1155/2017/6486859] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/24/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND One-stage direct-to-implant immediate breast reconstruction (IBR) is performed simultaneously with breast cancer resection. We explored indications, techniques, and outcomes of IBR to determine its feasibility, safety, and effectiveness. MATERIAL AND METHODS We reviewed the available literature on one-stage direct-to-implant IBR, with or without acellular dermal matrix (ADM), synthetic mesh, or autologous fat grafting. We analyzed the indications, preoperative work-up, surgical technique, postoperative care, outcomes, and complications. RESULTS IBR is indicated for small-to-medium nonptotic breasts and contraindicated in patients who require or have undergone radiotherapy, due to unacceptably high complications rates. Only patients with thick, well-vascularized mastectomy flaps are IBR candidates. Expandable implants should be used for ptotic breasts, while anatomical shaped implants should be used to reconstruct small-to-medium nonptotic breasts. ADMs can be used to cover the implant during IBR and avoid muscle elevation, thereby minimizing postoperative pain. Flap necrosis, reoperation, and implant loss are more common with IBR than conventional two-staged reconstruction, but IBR has advantages such as lack of secondary surgery, faster recovery, and better quality of life. CONCLUSIONS IBR has good outcomes and patient-satisfaction rates. With ADM use, a shift from conventional reconstruction to IBR has occurred. Drawbacks of IBR can be overcome by careful patient selection.
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Affiliation(s)
- Nicolò Bertozzi
- Department of Medicine and Surgery, Plastic Surgery Division, University of Parma, Parma, Italy
- Cutaneous, Mini-Invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
| | - Marianna Pesce
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Plastic Surgery Department, IRCCS San Martino University Hospital, National Institute for Cancer Research Genoa, Genoa, Italy
| | - Pierluigi Santi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Plastic Surgery Department, IRCCS San Martino University Hospital, National Institute for Cancer Research Genoa, Genoa, Italy
| | - Edoardo Raposio
- Department of Medicine and Surgery, Plastic Surgery Division, University of Parma, Parma, Italy
- Cutaneous, Mini-Invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
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A Meta-analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications. Ann Plast Surg 2017; 77:e31-8. [PMID: 22156884 DOI: 10.1097/sap.0b013e31822afae5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications. METHODS A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated. RESULTS A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014). CONCLUSION This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.
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Bertozzi N, Pesce M, Santi P, Raposio E. Tissue expansion for breast reconstruction: Methods and techniques. Ann Med Surg (Lond) 2017; 21:34-44. [PMID: 28765784 PMCID: PMC5526469 DOI: 10.1016/j.amsu.2017.07.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE In this work, the authors review recent data on the different methods and techniques of TE/implant-based reconstruction to determine the complication profiles and the advantages and disadvantages of the different techniques. This information will be valuable for surgeons performing breast reconstructions. MATERIALS AND METHODS A thorough literature review was conducted by the authors concerning the current strategy of tissue expander (TE)/implant-based breast reconstruction following breast cancer surgery. RESULTS Loss of the breast can strongly affect a woman's personal and social life while breast reconstruction reduces the sense of mutilation felt by women after a mastectomy, and provides psychosocial as well as aesthetic benefits. TE/implant-based reconstruction is the most common breast reconstructive strategy, constituting almost 65% of all breast reconstructions in the US. Although numerous studies have been published on various aspects of alloplastic breast reconstructions, most studies are single-center observations. No evidence-based guidelines are available as yet. Conventional TE/implant-based reconstruction can be performed as a two-stage procedure either in the immediate or delayed setting. Moreover, the adjunctive use of acellular dermal matrix further broadened the alloplastic breast reconstruction indication and also enhanced aesthetic outcomes. CONCLUSIONS TE/implant-based reconstruction has proved to be a safe, cost-effective, and reliable technique that can be performed in women with various comorbidities. Short operative time, fast recovery, and absence of donor site morbidity are other advantages over autologous breast reconstruction.
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Affiliation(s)
- Nicolò Bertozzi
- Department of Medicine and Surgery, Plastic Surgery Division, University of Parma, Cutaneous, Mini-invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Plastic Surgery Department, IRCCS San Martino University Hospital, National Institute for Cancer Research, Genoa, Italy
| | - Marianna Pesce
- Department of Plastic and Reconstructive Surgery, San Martino-IST University of Genova, Genova, Italy
| | - PierLuigi Santi
- Department of Plastic and Reconstructive Surgery, San Martino-IST University of Genova, Genova, Italy
| | - Edoardo Raposio
- Department of Medicine and Surgery, Plastic Surgery Division, University of Parma, Cutaneous, Mini-invasive, Regenerative and Plastic Surgery Unit, Parma University Hospital, Parma, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Plastic Surgery Department, IRCCS San Martino University Hospital, National Institute for Cancer Research, Genoa, Italy
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Agarwal S, Ettinger RE, Kung TA, Kozlow JH, Brown DL. Cohort study of immediate implant exchange during acute infection in the setting of breast reconstruction. J Plast Reconstr Aesthet Surg 2017; 70:865-870. [DOI: 10.1016/j.bjps.2017.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 03/19/2017] [Accepted: 03/29/2017] [Indexed: 11/30/2022]
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Abstract
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.
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Piper ML, Roussel LO, Koltz PF, Wang F, Singh K, Chin R, Sbitany H, Langstein HN. Characterizing infections in prosthetic breast reconstruction: A validity assessment of national health databases. J Plast Reconstr Aesthet Surg 2017; 70:1345-1353. [PMID: 28619483 DOI: 10.1016/j.bjps.2017.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 03/17/2017] [Accepted: 05/09/2017] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Merisa L Piper
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lauren O Roussel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter F Koltz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Frederick Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Kyra Singh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Robin Chin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Hani Sbitany
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Two-Stage Implant-Based Breast Reconstruction: An Evolution of the Conceptual and Technical Approach over a Two-Decade Period. Plast Reconstr Surg 2017; 138:1-11. [PMID: 27348635 DOI: 10.1097/prs.0000000000002243] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Over a two-decade period, the senior author (P.G.C.) has had extensive experience with two-stage implant-based breast reconstruction with total musculofascial coverage. During this period, the approach has evolved substantially. The evolution has been based on changes in breast cancer treatment, available technology and, most importantly, yearly evaluation of surgical outcomes. METHODS This article describes changes in the conceptual approach to breast reconstruction, and the resulting evolution of surgical techniques. Evolving concepts and current techniques are described as they relate to each consecutive stage of implant-based breast reconstruction. RESULTS For the first stage of breast reconstruction (i.e., placement of the tissue expander), key concepts and techniques described are the vertical mastectomy defect, the point of maximal expansion, the musculofascial pocket, and the inferior fasciotomy. For the second stage of breast reconstruction (i.e., the exchange procedure), key concepts and techniques described are implant selection, setting the inframammary fold, defining the inferolateral shape of the breast, and circumferential capsulotomy. CONCLUSION The purpose of this article is to relay the lessons learned from this long experience and to provide a conceptual and technical framework to two-stage implant-based breast reconstruction.
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How to Manage Complications in Breast Reconstruction. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Salvaging the Infected Breast Tissue Expander: A Standardized Multidisciplinary Approach. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e732. [PMID: 27482480 PMCID: PMC4956844 DOI: 10.1097/gox.0000000000000676] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 02/16/2016] [Indexed: 11/26/2022]
Abstract
Background: Infections of breast tissue expander (TE) are complex, often requiring TE removal and hospitalization, which can delay further adjuvant therapy and add to the overall costs of breast reconstruction. Therefore, to reduce the rate of TE removal, hospitalization, and costs, we created a standardized same-day multidisciplinary outpatient quality improvement protocol for diagnosing and treating patients with early signs of TE infection. Methods: We prospectively evaluated 26 consecutive patients who developed a surgical site infection between February 2013 and April 2014. On the same day, patients were seen in the Plastic Surgery and Infectious Diseases clinics, underwent breast ultrasonography with or without periprosthetic fluid aspiration, and were prescribed a standardized empiric oral or intravenous antimicrobial regimen active against biofilm-embedded microorganisms. All patients were managed as per our established treatment algorithm and were followed up for a minimum of 1 year. Results: TEs were salvaged in 19 of 26 patients (73%). Compared with TE-salvaged patients, TE-explanted patients had a shorter median time to infection (20 vs 40 days; P = 0.09), a significantly higher median temperature at initial presentation [99.8°F; interquartile range (IQR) = 2.1 vs 98.3°F; IQR = 0.4°F; P = 0.01], and a significantly longer median antimicrobial treatment duration (28 days; IQR = 27 vs 21 days; IQR = 14 days; P = 0.05). The TE salvage rates of patients whose specimen cultures yielded no microbial growth, Staphylococcus species, and Pseudomonas were 92%, 75%, and 0%, respectively. Patients who had developed a deep-seated pocket infection were significantly more likely than those with superficial cellulitis to undergo TE explantation (P = 0.021). Conclusions: Our same-day multidisciplinary diagnostic and treatment algorithm not only yielded a TE salvage rate higher than those previously reported but also decreased the rate of hospitalization, decreased overall costs, and identified several clinical scenarios in which TE explantation was likely.
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Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction. Ann Plast Surg 2016; 75:24-8. [PMID: 25003412 DOI: 10.1097/sap.0000000000000142] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Two-stage tissue expander-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure. METHODS A retrospective review of tissue expander-based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap. RESULTS A total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation). CONCLUSIONS Women with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.
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Cone EB, Lentz AC. Percutaneous Revision of a Testicular Prosthesis is Safe, Cost-effective, and Provides Good Patient Satisfaction. Urol Case Rep 2015; 3:129-31. [PMID: 26793527 PMCID: PMC4672670 DOI: 10.1016/j.eucr.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/20/2015] [Indexed: 11/26/2022] Open
Abstract
Office-based percutaneous revision of a testicular prosthesis has never been reported. A patient received a testicular prosthesis but was dissatisfied with the firmness of the implant. In an office setting, the prosthesis was inflated with additional fluid via a percutaneous approach. Evaluated outcomes included patient satisfaction, prosthesis size, recovery time, and cost savings. The patient was satisfied, with no infection, leak, or complication after more than 1 year of follow-up, at significantly less cost than revision surgery. Percutaneous adjustment of testicular prosthesis fill-volume can be safe, inexpensive, and result in good patient satisfaction.
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Affiliation(s)
- Eugene B. Cone
- Corresponding author. Tel.: +1 919 684 2033; fax: +1 919 684 4611.
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Gabriel A, Champaneria MC, Maxwell GP. The efficacy of botulinum toxin A in post-mastectomy breast reconstruction: a pilot study. Aesthet Surg J 2015; 35:402-9. [PMID: 25825421 DOI: 10.1093/asj/sjv040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Botulinum toxin A has been successfully used in a variety of areas to temporarily obliterate muscle mobility for either functional or aesthetic gain. Tissue expander-based breast reconstruction has been plagued with pain and discomfort. OBJECTIVE The purpose of this pilot study was to evaluate the role of a neurotoxin (Botulinum toxin A) in expander-based breast reconstruction. METHODS Thirty patients underwent mastectomies with immediate expander or acellular dermal matrix reconstruction. The neurotoxin group (n = 15) received 40 units of neurotoxin (Botulinum toxin A, Allergan, Inc, Irvine, CA) into each pectoralis major muscle through 4 serial injections and the placebo group (n = 15) received 4 serial injections of 0.9% NaCl. All patients were followed over 1 year, and patient demographics, VAS (visual analog score), laterality, office visits, amount of expansion and number of times to full expansion, and amount of narcotics required were recorded. Statistical significance was considered as p < .05. RESULTS There were no significant differences between the two groups in terms of age, laterality, expander size, or complications (p = .46-.66). There was a significant difference between the two groups in the VAS score, demonstrating decreased pain in the neurotoxin group (p < .05). In addition, there was a significant increase in the volume of expansion per visit in the neurotoxin group as compared to the placebo group (p < .05). There was no significant difference in narcotic use in the first 3 days after surgery; however, there was a significant decrease in use of narcotics from 7 to 45 days in the neurotoxin group (p < .05). There were no complications associated with the use of the neurotoxin. CONCLUSIONS The infiltration of the pectoralis major muscle with neurotoxin in immediate, expander-based reconstruction may be beneficial in reducing pain and expediting expansions.
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Affiliation(s)
- Allen Gabriel
- Drs Gabriel and Maxwell are Associate Clinical Professors in the Department of Plastic Surgery at the Loma Linda University Medical Center, Loma Linda, CA. Dr Champaneria is a plastic surgeon in private practice in Vancouver, WA
| | - Manish C Champaneria
- Drs Gabriel and Maxwell are Associate Clinical Professors in the Department of Plastic Surgery at the Loma Linda University Medical Center, Loma Linda, CA. Dr Champaneria is a plastic surgeon in private practice in Vancouver, WA
| | - G Patrick Maxwell
- Drs Gabriel and Maxwell are Associate Clinical Professors in the Department of Plastic Surgery at the Loma Linda University Medical Center, Loma Linda, CA. Dr Champaneria is a plastic surgeon in private practice in Vancouver, WA
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Assessment of patient factors, surgeons, and surgeon teams in immediate implant-based breast reconstruction outcomes. Plast Reconstr Surg 2015; 135:245e-252e. [PMID: 25626807 DOI: 10.1097/prs.0000000000000912] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Outcome studies of immediate implant-based breast reconstruction have focused largely on patient factors, whereas the relative impact of the surgeon as a contributing variable is not known. As the procedure requires collaboration of both a surgical oncologist and a plastic surgeon, the effect of the surgeon team interaction can have a significant impact on outcome. This study examines outcomes in implant-based breast reconstruction and the association with patient characteristics, surgeon, and surgeon team familiarity. METHODS A retrospective review of 3142 consecutive implant-based breast reconstruction mastectomy procedures at one institution was performed. Infection and skin necrosis rates were measured. Predictors of outcomes were identified by unadjusted logistic regression followed by multivariate logistic regression. Surgeon teams were grouped according to number of cases performed together. RESULTS Patient characteristics remain the most important predictors for outcomes in implant-based breast reconstruction, with odds ratios above those of surgeon variables. The authors observed significant differences in the rate of skin necrosis between surgical oncologists with an approximately two-fold difference between surgeons with the highest and lowest rates. Surgeon teams that worked together on fewer than 150 procedures had higher rates of infection. CONCLUSIONS Patient characteristics are the most important predictors for surgical outcomes in implant-based breast reconstruction, but surgeons and surgeon teams are also important variables. High-volume surgeon teams achieve lower rates of infection. This study highlights the need to examine modifiable risk factors associated with optimum implant-based breast reconstruction outcomes, which include patient and provider characteristics and the surgical team treating the patient. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction. Plast Reconstr Surg 2015; 135:253e-261e. [PMID: 25626808 DOI: 10.1097/prs.0000000000000988] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older breast cancer patients undergo postmastectomy breast reconstruction infrequently, in part because of a perception of increased surgical risk. This study sought to investigate the effects of age on perioperative complications after postmastectomy breast reconstruction. METHODS The American College of Surgeons National Surgery Quality Improvement Program Participant Use Files from 2005 to 2012 were used to identify women with breast cancer who underwent unilateral mastectomy alone or with immediate reconstruction. Thirty-day complication rates were compared between younger (<65 years) and older (≥65 years) women after implant-based reconstruction, autologous reconstruction, or mastectomy alone. Linear and logistic regression models were used to control for differences in comorbidities and age. RESULTS A total of 40,769 patients were studied, of whom 15,093 (37 percent) were aged 65 years or older. Breast reconstruction was performed in 39.5 percent of younger and 10.7 percent of older women. The attributable risks of breast reconstruction, manifested by longer hospital stays (p < 0.001), more frequent complications (p < 0.001), and more reoperations (p < 0.001), were similar in older and younger women. There were no differences in the adjusted complication rates between older and younger patients undergoing implant-based reconstruction. However, older women undergoing autologous reconstruction were more likely to suffer venous thromboembolism (OR, 3.67; p = 0.02). CONCLUSIONS The perioperative risks attributable to breast reconstruction are similar in older and younger women. Older patients should be counseled that their age does not confer an increased risk of complications after implant-based breast reconstruction. However, age is an independent risk factor for venous thromboembolism after autologous reconstruction. Special attention should be paid to venous thromboembolism prophylaxis in this group. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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The impact of chemotherapy and radiation therapy on the remodeling of acellular dermal matrices in staged, prosthetic breast reconstruction. Plast Reconstr Surg 2015; 135:43e-57e. [PMID: 25539350 DOI: 10.1097/prs.0000000000000807] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND An acellular dermal matrix will typically incorporate, in time, with the overlying mastectomy skin flap. This remodeling process may be adversely impacted in patients who require chemotherapy and radiation, which influence neovascularization and cellular proliferation. METHODS Multiple biopsy specimens were procured from 86 women (n = 94 breasts) undergoing exchange of a tissue expander for a breast implant. These were divided by biopsy location: submuscular capsule (control) as well as superiorly, centrally, and inferiorly along the paramedian acellular dermis. Specimens were assessed for cellular infiltration, cell type, fibrous encapsulation, scaffold degradation, extracellular matrix deposition, neovascularization, mean composite remodeling score, and type I and III collagen. Patients were compared based on five oncologic treatment groups: no adjuvant therapy (untreated), neoadjuvant chemotherapy with or without radiation, and chemotherapy with or without radiation. RESULTS Biopsy specimens were procured 45 to 1805 days after implantation and demonstrated a significant reduction in type I collagen over time. Chemotherapy adversely impacted fibrous encapsulation (p = 0.03). Chemotherapy with or without radiation adversely impacted type I collagen (p = 0.02), cellular infiltration (p < 0.01), extracellular matrix deposition (p < 0.04), and neovascularization (p < 0.01). Radiation exacerbated the adverse impact of chemotherapy for several remodeling parameters. Neoadjuvant chemotherapy also caused a reduction in type I (p = 0.01) and III collagen (p = 0.05), extracellular matrix deposition (p = 0.03), and scaffold degradation (p = 0.02). CONCLUSION Chemotherapy and radiation therapy limit acellular dermal matrix remodeling. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Ota D, Fukuuchi A, Iwahira Y, Kato T, Takeuchi M, Okamoto J, Nishi T. Identification of complications in mastectomy with immediate reconstruction using tissue expanders and permanent implants for breast cancer patients. Breast Cancer 2014; 23:400-6. [PMID: 25548068 DOI: 10.1007/s12282-014-0577-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 12/09/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since complications of postmastectomy breast reconstruction may reduce patient satisfaction, we investigated complications of reconstruction with tissue expanders (TEs), particularly surgical site infections requiring TE/permanent implant (PI) removal. PATIENTS AND METHODS A retrospective review was performed of 234 primary breast cancer patients undergoing 239 postmastectomy breast reconstructions with TEs/PIs from 1997 to 2009. Clinicopathological findings and postoperative complications, particularly infections, were analyzed. Data were analyzed by the Chi-square test and a multivariate logistic regression model. TE infection risk factors considered for model inclusion were excisional biopsy, (neo) adjuvant chemotherapy, lymph node resection, body mass index (BMI), simultaneous bilateral reconstructions, and seroma aspiration. RESULTS Removal of TEs/PIs was observed in 15.5% (37/239) of reconstructions, and 18/37 underwent re-reconstructions. Of the 19/37 reconstructions that were not achieved completely, the most frequent reason was TE infection (11 reconstructions). The completion rate was 92% (220/239 reconstructions) and it was significantly higher in reconstructions without TE infection than with infection (96 vs. 54%, p < 0.0001). Patients with BMI ≥ 25 kg/m² and seroma aspiration were more likely to develop TE infections (p = 0.0019, p < 0.001, respectively). By multivariate logistic regression analysis, seroma aspiration was a significant independent risk factor for TE infection (odds ratio 28.75, 95% confidence interval 5.71-40.03, p < 0.0001). CONCLUSION To improve completion rates of breast reconstruction, prevention of TE infection plays a key role. We should reduce unnecessary seroma aspirations and delay elevation/exercise of the ipsilateral arm.
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Affiliation(s)
- Daisuke Ota
- Department of Breast and Endocrine Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo, 101-8643, Japan.
| | - Atsushi Fukuuchi
- Department of Breast and Endocrine Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Yoshiko Iwahira
- Breast Surgery Clinic, 2-21-43 Takanawa, Minato-ku, Tokyo, 108-0074, Japan
| | - Takao Kato
- Department of Breast and Endocrine Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Masashi Takeuchi
- Department of Breast and Endocrine Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo, 101-8643, Japan
| | - Joji Okamoto
- Department of Surgery, Nippon Kokan Hospital, 1-2-1 Kokandori, Kawasaki-ku, Kawasaki, Kanagawa, 210-0852, Japan
| | - Tsunehiro Nishi
- Department of Breast and Endocrine Surgery, Mitsui Memorial Hospital, 1 Kanda-Izumicho, Chiyoda-ku, Tokyo, 101-8643, Japan
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Breast reconstruction with tissue expanders: implementation of a standardized best-practices protocol to reduce infection rates. Plast Reconstr Surg 2014; 134:11-18. [PMID: 25028815 DOI: 10.1097/prs.0000000000000261] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors' goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections. METHODS A comprehensive, best-practices protocol was introduced and implemented in November of 2010. All patients undergoing breast reconstruction using tissue expanders at the authors' institution in the 5 years before the protocol, and in the 2 years after, were analyzed. RESULTS Three hundred five patients underwent 456 tissue expander reconstructions in the 5 years before the protocol, and 198 patients underwent 313 reconstructions in the 2 years after. Significantly fewer patients developed periprosthetic infection after protocol (11.6 percent versus 18.4 percent; p=0.042), and the number of infected tissue expanders trended toward a decrease (9.3 percent versus 13.2 percent; p=0.097). On multivariate analysis, the protocol significantly reduced the odds of periprosthetic infection (OR, 0.45; p=0.022). Predictors of infection included obesity (OR, 2.01; p=0.045) and preoperative breast size larger than C cup (OR, 2.83; p=0.006). CONCLUSIONS The authors' comprehensive, best-practices protocol allowed them to reduce the odds of tissue expander infections by 55 percent (OR, 0.45; p=0.022). The authors were able to identify several potential areas of improvement that may help them lower the rate of infection further in the future. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Fischer JP, Wes AM, Nelson JA, Basta M, Rohrbach JI, Wu LC, Serletti JM, Kovach SJ. Propensity-matched, longitudinal outcomes analysis of complications and cost: comparing abdominal free flaps and implant-based breast reconstruction. J Am Coll Surg 2014; 219:303-12. [PMID: 24916480 DOI: 10.1016/j.jamcollsurg.2014.02.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/14/2014] [Accepted: 02/17/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Choosing a breast reconstructive modality after mastectomy is an important step in the reconstructive process. The authors hypothesized that autologous tissue is associated with a greater success rate and cost efficacy over time, relative to implant reconstruction. STUDY DESIGN A retrospective review was performed of patients undergoing free tissue (FF) transfer and expander implant (E/I) reconstruction between 2005 and 2011. Variables evaluated included comorbidities, surgical timing, complications, overall outcomes, unplanned reoperations, and costs. A propensity-matching technique was used to account for the nonrandomized selection of modality. RESULTS A total of 310 propensity-matched patients underwent 499 reconstructions. No statistically significant differences in preoperative variables were noted between propensity-matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. The E/I reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs 1.2%, p < 0.001). Expander implant reconstructions were associated with higher rates of seroma (p = 0.009) and lower rates of medical complications (p = 0.02), but overall significantly higher rates of unplanned operations (15.5% vs 5.8%, p = 0.002). The total cost of reconstruction did not differ significantly between groups ($23,120.49 ± $6,969.56 vs $22,739.91 ± $9,727.79, p = 0.060), but E/I reconstruction was associated with higher total cost for secondary procedures ($10,157.89 ± $8,741.77 vs $3,200.71 ± $4,780.64, p < 0.0001) and a higher cost of unplanned revisions over time (p < 0.05). CONCLUSIONS Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost. Although autologous reconstruction is not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.
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Affiliation(s)
- John P Fischer
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Ari M Wes
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jonas A Nelson
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marten Basta
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jeffrey I Rohrbach
- Division of Finance, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Liza C Wu
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joseph M Serletti
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA
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Fischer JP, Wes AM, Tuggle CT, Serletti JM, Wu LC. Risk Analysis of Early Implant Loss after Immediate Breast Reconstruction: A Review of 14,585 Patients. J Am Coll Surg 2013; 217:983-90. [DOI: 10.1016/j.jamcollsurg.2013.07.389] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 07/10/2013] [Accepted: 07/10/2013] [Indexed: 11/25/2022]
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Viola GM, Raad II, Rolston KV. Breast tissue expander-related infections: perioperative antimicrobial regimens. Infect Control Hosp Epidemiol 2013; 35:75-81. [PMID: 24334802 DOI: 10.1086/674390] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The rate of postmastectomy tissue expander (TE) infection remains excessively high, ranging between 2% and 24%. We hypothesized that current perioperative antimicrobial regimens utilized for breast TE reconstruction may be outdated as a result of recent changes in microflora and susceptibility patterns. DESIGN AND METHODS We reviewed the records of all patients who had a TE reconstructive procedure and developed a definite breast TE infection between 2003 and 2010 at MD Anderson Cancer Center. Antimicrobials were stratified into 3 groups: systemic perioperative, local irrigation, and oral immediate postoperative antimicrobials. These were considered discordant if they did not target the isolated organisms, while a breakthrough infection was defined as an infection that occurred despite concordant antimicrobial coverage. RESULTS Overall, 75 patients with a definite TE infection were identified. The most common organisms identified were methicillin-resistant Staphylococcus epidermidis (29%), methicillin-resistant Staphylococcus aureus (15%), and gram-negative rods (26%). The use of systemic perioperative antimicrobials was deemed discordant in 51% of the cases. Although 79% of the patients received broad-spectrum perioperative local antimicrobial irrigation, 63% developed a breakthrough infection. Even though 61% received oral postoperative prophylactic antimicrobials, 63% of the times they were deemed discordant. CONCLUSIONS Contrary to the proven effectiveness of a single dose of perioperative antibiotics, the common use of local antimicrobial irrigation and prolonged postoperative oral antibiotics appears to be an inadequate component of our preventive armamentarium. Also, because methicillin-resistant staphylococcal and pseudomonal infections occurred approximately 60% of the time, at institutions that have observed an increase of these organisms, it may be prudent that perioperative antimicrobials target these microorganisms.
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Affiliation(s)
- George M Viola
- Division of Medicine, Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, Houston, Texas
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Fischer JP, Nelson JA, Serletti JM, Wu LC. Peri-operative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): A review of 9305 patients from the 2005–2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg 2013; 66:1504-12. [DOI: 10.1016/j.bjps.2013.06.030] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/10/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
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Kato H, Nakagami G, Iwahira Y, Otani R, Nagase T, Iizaka S, Tamai N, Matsuyama Y, Sanada H. Risk Factors and Risk Scoring Tool for Infection during Tissue Expansion in Tissue Expander and Implant Breast Reconstruction. Breast J 2013; 19:618-26. [DOI: 10.1111/tbj.12175] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Hirofumi Kato
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | | | | | - Takashi Nagase
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Shinji Iizaka
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Nao Tamai
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Yutaka Matsuyama
- Department of Biostatistics; School of Public Health; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
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Miller ME, Czechura T, Martz B, Hall ME, Pesce C, Jaskowiak N, Winchester DJ, Yao K. Operative risks associated with contralateral prophylactic mastectomy: a single institution experience. Ann Surg Oncol 2013; 20:4113-20. [PMID: 23868655 DOI: 10.1245/s10434-013-3108-1] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to determine if newly diagnosed breast cancer patients undergoing contralateral prophylactic mastectomy (CPM) experience more complications than patients undergoing unilateral mastectomy (UM). METHODS A total of 600 patients underwent either UM or CPM between January 2009 and March 2012 for unilateral breast cancer. Operative complications were classified as minor (aspirations, infection requiring antibiotics, partial flap and nipple necrosis, minor bleeding, delayed wound healing) or major (hematoma or seroma requiring operation, infection requiring rehospitalization, blood product transfusion, total flap or nipple loss, implant removal), mixed (both minor and major complications), or multiple. Chi-square and multivariate logistic regressions were used for the analysis. RESULTS Of the 600 patients, 391 (65 %) underwent UM and 209 (35 %) underwent CPM. Across all complication groups, there were significantly more complications in the CPM group versus the UM group (41.6 vs. 28.6 %, p = 0.001). Major complications alone were significantly greater in the CPM versus the UM group (13.9 vs. 4.1 %, p < 0.001). When adjusting for age, body mass index, smoking and diabetes history, AJCC stage, reconstruction, previous radiation therapy, and adjuvant therapy, CPM patients were 1.5 times more likely to have any complication (odds ratio [OR] 1.53; 95 % CI 1.04-2.25, p = 0.029) and 2.7 times more likely to have a major complication compared with UM patients (OR 2.66; 95 % CI 1.37-5.19, p = 0.004). CONCLUSIONS CPM patients have an increased risk of complications, especially major complications requiring rehospitalization or reoperation. These complications may influence patient and physician decisions to choose CPM.
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Affiliation(s)
- Megan E Miller
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA,
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Hanwright PJ, Davila AA, Mioton LM, Fine NA, Bilimoria KY, Kim JYS. A predictive model of risk and outcomes in tissue expander reconstruction: a multivariate analysis of 9786 patients. J Plast Surg Hand Surg 2013; 47:513-8. [PMID: 23627559 DOI: 10.3109/2000656x.2013.789436] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Outcomes of tissue expander breast reconstruction show variability based on presurgical risk factors. Few comprehensive, multi-institutional risk analyses exist. Patients who underwent tissue expander reconstruction were identified in a multi-institutional registry that spans over 240 institutions with over 200 variables per patient. Bivariate analysis of preoperative variables was performed across outcomes. Multivariate logistic regression was used to adjust for confounders and identify risk factors for complications. In 9786 total tissue expander patients, 526 (5.38%) patients experienced one or more complications. Wound infection and reoperations occurred in 3.45% and 6.76% of patients, respectively. Body mass index (BMI) was found to be a significant independent risk factor for overall morbidity, reoperation, prosthesis failure, and wound infection. Overweight, obese, and morbidly obese patients were at 1.7-, 2.6-, and 5.1-times greater risk of morbidity, respectively (p < 0.001 for all). Reconstructive timing, combined surgical procedures, and neoadjuvant chemotherapy were not found to be significant predictors of morbidity. The odds of developing complications were 1.5- and 1.3-times greater in smokers and patients over the age of 50, respectively (p = 0.001 and p = 0.015). For each additional hour of surgery, the odds of morbidity increased 1.26-times (p < 0.001). Precise risk profiles garnered from multi-institutional studies can help improve patient selection and education. Overall, tissue expander reconstruction was found to be safe, with relatively few complications. Operative time, BMI, and smoking were consistently found to be independent risk factors for postoperative morbidity.
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Al-Mufarrej FM, Woods JE, Jacobson SR. Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction. J Plast Reconstr Aesthet Surg 2013; 66:747-55. [PMID: 23602672 DOI: 10.1016/j.bjps.2013.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 01/02/2013] [Accepted: 02/12/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND In some patients, a satisfactory aesthetic result of reconstruction following a nipple-sparing mastectomy (NSM) is limited by breast ptosis that goes uncorrected in the early phase of reconstruction. Most plastic surgeons remain hesitant to perform a mastopexy at the time of NSM due to concerns with nipple and/or skin flap loss. METHODS From 1990 to 1995, 33 female patients underwent NSM with simultaneous mastopexy and immediate implant-based reconstruction by a single surgeon at our institution. On chart review, the following data were extracted: age, co-morbidity, indication, breast size, initial/final implant volumes, type of implant, mastopexy technique, mastectomy flap/nipple necrosis, other complications, revision surgery and follow-up. An unpaired, two-tailed t-test was performed where indicated. P-value<0.05 was considered significant. RESULTS Wound complications occurred in 18.2% patients (10.9% breasts) without delaying tissue expansion. As many as 3% patients developed unilateral, isolated partial ischaemia of the mastectomy flap and 8% patients developed unilateral, superficial areolar loss. All resolved with conservative treatment. Only one patient developed bilateral total nipple loss. There was no correlation between preoperative breast size and postoperative complications. None of the patients developed breast cancer. Average follow-up was 11.6 years. CONCLUSION With proper technique, simultaneous mastopexy is a safe procedure in highly selected patients undergoing NSM with reconstruction.
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Affiliation(s)
- F M Al-Mufarrej
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905, USA
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Mioton LM, Smetona JT, Hanwright PJ, Seth AK, Wang E, Bilimoria KY, Gaido J, Fine NA, Kim JYS. Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients? J Plast Reconstr Aesthet Surg 2013; 66:917-25. [PMID: 23562485 DOI: 10.1016/j.bjps.2013.03.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/20/2012] [Accepted: 03/05/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes. METHODS Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL). RESULTS A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes. CONCLUSIONS Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.
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Affiliation(s)
- Lauren M Mioton
- Department of Plastic Surgery, Vanderbilt School of Medicine, Nashville, TN, USA
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Howard-McNatt MM. Patients opting for breast reconstruction following mastectomy: an analysis of uptake rates and benefit. BREAST CANCER-TARGETS AND THERAPY 2013; 5:9-15. [PMID: 24648753 DOI: 10.2147/bctt.s29142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
For women with breast cancer who undergo a mastectomy, breast reconstruction offers improved psychological and cosmetic outcomes. We analyzed the rates of breast reconstruction and potential benefits to these women. The review was based on a PubMed search using the terms "reconstruction," "mastectomy," "rates," "benefits," and "breast cancer." Breast-reconstruction rates have continued to rise in recent years; however, there are definite barriers to widespread use of this procedure. These barriers include age, ethnicity, income, tumor characteristics, and the need for adjuvant radiation therapy. There are notable psychological advantages to women who receive breast reconstruction. These women also express an improved quality of life. Breast reconstruction is an acceptable technique for women undergoing mastectomy. It should be offered to all women in an immediate or delayed fashion, with guidance from their physician about the benefits and risks.
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Garvey PB, Villa MT, Rozanski AT, Liu J, Robb GL, Beahm EK. The advantages of free abdominal-based flaps over implants for breast reconstruction in obese patients. Plast Reconstr Surg 2013; 130:991-1000. [PMID: 23096600 DOI: 10.1097/prs.0b013e318267efc5] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The authors hypothesized that, for obese patients, delayed abdominal-based free flap (rather than implant-based and immediate) breast reconstruction would result in fewer overall complications and reconstruction losses. METHODS The authors retrospectively analyzed consecutive implant- and abdominal-based free flap breast reconstructions performed in obese patients between 2005 and 2010 by utilizing the World Health Organization obesity classifications: class I, 30.0 to 34.9 kg/m2; class II, 35.0 to 39.9 kg/m2; and class III, ≥40 kg/m2. Primary outcome measures included flap failures and overall complications. Logistic regression analysis identified associations among patient, defect, and reconstructive characteristics and surgical outcomes. RESULTS The analysis included 990 breast reconstructions (548 flaps versus 442 implants) in 700 patients. Mean follow-up was 17 months. Age, smoking, medical illness, and body mass index greater than 37 predicted overall complications on regression analysis. Implants demonstrated a higher failure rate (15.8 percent) than flaps (1.5 percent). Although failure rates were similar for immediate and delayed flap reconstructions overall (1.3 versus 1.9 percent) and among obesity classifications, there was a trend toward more implant failures in immediate rather than delayed reconstructions (16.8 versus 5.3 percent). Differences between immediate implant versus flap reconstruction failure rates were highest among more obese patients [class II (24.7 versus 1.3 percent) and class III (25.4 versus 0 percent) compared with class I (11.7 versus 1.4 percent)]. CONCLUSIONS Obese patients (particularly class II and III) experience higher failure rates with implant-based breast reconstruction, particularly immediate reconstruction. Free flap techniques or delayed implant reconstruction may be warranted in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Patrick B Garvey
- Houston, Texas From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center
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The use of acellular dermal matrices in two-stage expander/implant reconstruction: a multicenter, blinded, randomized controlled trial. Plast Reconstr Surg 2013; 130:57S-66S. [PMID: 23096987 DOI: 10.1097/prs.0b013e31825f05b4] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current efficacy data supporting the routine use of acellular dermal matrices in postmastectomy tissue expander/implant reconstruction are limited. A multicenter, blinded, randomized controlled study was designed to evaluate the effectiveness of acellular dermal matrix in the setting of tissue expander/implant reconstruction. The primary objective of the study was to determine whether the use of matrix would decrease patient-reported postoperative pain. The secondary objective was to determine whether its use would accelerate the rate of postoperative expansion. METHODS The randomized controlled trial was conducted at two U.S. centers from 2008 to 2011. Immediately following mastectomy, all patients were randomized to one of two treatment arms: (1) acellular dermal matrix-assisted, tissue expander/implant reconstruction; and (2) submuscular tissue expander/implant placement. All patients were blinded to their treatment arm. RESULTS One hundred eight consented to participate; 38 were excluded prior to randomization. In total, 70 patients were randomized. There were no differences seen in immediate postoperative pain (p = 0.19) or pain during the expansion phase (p = 0.65) between treatment arms. There was similarly no difference in postoperative narcotic use (p = 0.38). The rate of postoperative expansion did not differ between groups (p = 0.83). CONCLUSIONS The results suggest that the use of acellular dermal matrix in the setting of tissue expander/implant reconstruction neither reduces postoperative pain nor accelerates the rate of postoperative expansion. An examination of its efficacy in improving long-term outcomes following tissue expander/implant reconstruction is warranted.
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Once is not enough: withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of infection. Plast Reconstr Surg 2012; 130:495-502. [PMID: 22575852 DOI: 10.1097/prs.0b013e31825dbefe] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND There has been a trend toward limiting perioperative prophylactic antibiotics, based on research not conducted in plastic surgery patients. The authors' university hospital instituted antibiotic prescribing guidelines based on the Surgical Care Improvement Project. An increased rate of surgical-site infections was noted in breast reconstruction patients. The authors sought to determine whether the change in antibiotic prophylaxis regimen affected rates of surgical-site infections. METHODS A retrospective study compared patients undergoing breast reconstruction who received preoperative and postoperative prophylactic antibiotics with a group who received only a single dose of preoperative antibiotic. Type of reconstruction and known risk factors for implant infection were noted. RESULTS Two hundred fifty patients were included: 116 in the pre-Surgical Care Improvement Project group and 134 in the Surgical Care Improvement Project group. The overall rate of surgical-site infections increased from 18.1 percent to 34.3 percent (p = 0.004). Infections requiring reoperation increased from 4.3 percent to 16.4 percent (p = 0.002). Multivariate logistic regression demonstrated that patients in the Surgical Care Improvement group were 4.74 times more likely to develop a surgical-site infection requiring reoperation (95 percent CI, 1.69 to 13.80). Obesity, history of radiation therapy, and reconstruction with tissue expanders were associated with increased rates of surgical-site infection requiring reoperation. CONCLUSIONS Withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of surgical-site infection, reoperation, and thus reconstructive failure. The optimal duration of postoperative prophylactic antibiotic use is the subject of future study.
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