Veritas in Immediate Implant-based Breast Reconstruction Is Associated with Higher Complications Compared with TiLOOP

Red Breast Syndrome-Where Has It Gone?: A Systematic Review of Red Breast Syndrome Incidence Overtime

BACKGROUND

Red breast syndrome (RBS) has been noted in past literature as a possible complication of implant-based breast reconstruction (IBBR) with the use of acellular dermal matrices (ADMs). Since its first appearance in 2009, RBS has drawn growing medical attention with reported incidence ranging from 7%-9%. There has been a noted decrease in the emergence of RBS despite its inclusion among the analyzed complications in a number of studies. This systematic review aims to evaluate the trend in reported RBS incidence over time and appropriately determine an accurate incidence of RBS from reported literature since the emergence of the phenomena.

METHODS

A systematic literature review was performed in July 2023 that analyzed the incidence of RBS among retrospective cohort studies on complication rates of IBBR with ADM. Patient demographics, RBS incidence rates, and all-cause complications were captured. The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and Methodological Index for Nonrandomized Studies criteria was used to assess study quality.

RESULTS

From 2009 to 2023, a total of 48 studies (n = 6251) met inclusion criteria of which 35 studies from 2017 to 2023 were not already included in a prior systematic review (n = 5246). The mean incidence of RBS in the unreported studies was 2.88% with a weighted mean of 3.22%. Analysis of the trend in RBS over time shows an increasing reported incidence rate from 2009 with a peak in incidence between 2016 and 2017, followed by a steady decline through 2022. Twenty-six of the studies were published from 2016 to 2019.

CONCLUSIONS

The incidence of RBS among prior studies and systematic reviews has fluctuated significantly since its initial emergence in 2009. Reported incidence rates have been on the decline since 2018 with a true weighted incidence of 3.22% from analysis of recent reported studies. Potential causes for the decline in incidence include practice changes in ADM preparation, changes in the ADM brand used for IBBR, and improved categorization of RBS compared to cellulitis/infection. Despite more robust criteria for diagnosis, no consensus for management has yet been established.

The Usage of Mesh and Relevant Prognosis in Implant Breast Reconstruction Surgery: A Meta-analysis

BACKGROUND

Although mesh-based implant breast reconstruction surgery is emerging as the primary surgical procedure for breast reconstruction, mesh use remains controversial in implant breast reconstruction surgery, especially in terms of how to select the ideal mesh. Our aim is to elaborate relevant prognosis in the mesh-based implant breast reconstruction surgery.

METHODS

Relevant studies were identified from PubMed, Web of Science, EMBASE, and Cochrane library searches. Extracted data included study type, basic characteristics, mesh information, complications, etc. We analyzed the included cohort studies and randomized controlled trials that reported mesh-related implant breast reconstruction complications and breast quality scale scores.

RESULTS

A total of 32 studies including 7475 subjects were included. The results showed that the overall complication rate was 2.07 times higher in the biological mesh group than in the synthetic mesh group (risk ratio [RR]: 2.07, 95% CI 1.14-3.78). The risk of seroma was 4.50 times higher in the biological mesh group than in the synthetic mesh group (RR: 4.50, 95% CI 2.27-8.95). In terms of comparing breast quality scale scores, the mesh group had scores that were 1.49 (95% CI 0.19-2.78) higher than the non-mesh group for "physical well-being" and 2.05 (95% CI 0.08-4.02) higher for "sexual well-being."

CONCLUSIONS

Our study found that the risk of total complications was higher with biological mesh than with synthetic mesh in implant breast reconstruction surgery. Based on short-term cost, healthcare burden, and healthcare benefits, synthetic meshes are superior to biological meshes.

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 .

A Systematic Review and Meta-Analysis of Synthetic Mesh Outcomes in Alloplastic Breast Reconstruction

Background

Mesh implants are frequently employed in alloplastic breast reconstruction. Notably, no mesh to date has FDA approval for this indication. Several synthetic meshes have been introduced with heterogeneous properties and outcomes.

Objectives

This study aims to systematically review synthetic mesh use in alloplastic breast reconstruction, describe rates of short-term complications, and analyze these outcomes in reports comparing synthetic and biologic meshes. The authors hypothesized data from comparative and noncomparative studies would show no significant differences between synthetic and biological meshes.

Methods

The authors conducted a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty-one studies reporting the use of synthetic mesh and clinical outcomes were included. Eight studies directly comparing synthetic mesh and biological mesh were meta-analyzed for relative risk (RR). Nineteen noncomparative studies were analyzed for meta-rates. Outcomes, including seroma, infection, reoperation, and explant, were assessed on a per-breast basis. Resultant models were challenged for sensitivity and bias.

Results

Meta-analysis of comparative studies demonstrated no difference in the risk of infection with synthetic mesh (RR = 0.53; 95% CI [0.26-1.10]), but a reduced risk of reoperation (RR = 0.54; 95% CI [0.33-0.89]) or explant (RR = 0.43; 95% CI [0.21-0.87]). Meta-analysis of noncomparative studies demonstrated rates of seroma = 3%; 95% CI [1%-6%], infection = 4%; 95% CI [3%-6%], reoperation = 10%; 95% CI [7%-13%], and explant = 3%; 95% CI [2%-5%]).

Conclusions

Studies comparing synthetic and biologic meshes demonstrated noninferiority of synthetic in all outcomes assessed. Noncomparative studies demonstrated rates of seroma, infection, reoperation, and explant similar to literature values for biological mesh.

Level of Evidence 2 Risk

Application of TiLOOP bra in implant-based breast reconstruction is associated with decreased complication risk compared with other meshes: A systematic review and meta-analysis

BACKGROUND

TiLOOP bra has been used for over 15 years, however, evidence regarding its safety in implant-based breast reconstruction (IBBR) for patients with breast cancer after mastectomy is still limited. We performed this meta-analysis to evaluate its risks and benefits in IBBR comparing with other meshes.

METHODS

Electronic databases were searched to identify relevant studies comparing postoperative complications between TiLOOP bra and other reconstruction techniques in IBBR with or without meshes. We also compared patient satisfaction in physical well-being between two groups. Risk ratios (RRs) and mean differences with 95% confidence interval (CI) were calculated.

RESULTS

Seven studies representing 1203 cases were analyzed. Compared with other meshes, the use of TiLOOP bra significantly reduced the risk of infection (RR = 0.53, 95% CI, 0.32-0.86), seroma (RR = 0.21, 95% CI, 0.07-0.61), red breast syndrome (RR = 0.10, 95% CI, 0.02-0.45), and capsular contracture (RR = 0.20, 95% CI, 0.05-0.75). Patient satisfaction in physical well-being was comparable between two groups.

CONCLUSIONS

TiLOOP bra in IBBR has a favored safety profile over other meshes, which significantly reduced postoperative complication risk and did not affect patient satisfaction. Although prospective well-designed controlled studies are still warranted, TiLOOP bra is safe and reliable at present.

Implant-Based Breast Reconstruction with Bovine Pericardium: Our Approach Using Tutopatch® and Review of Literature

OBJECTIVES

To describe the usage and advantages of bovine pericardium mesh (Tutopatch®) in breast reconstruction and to compare different mesh materials used in immediate breast reconstruction.

METHODS

Our study involved a single-center, retrospective analysis of 103 patients (comprising 114 breasts) who underwent immediate implant-based breast reconstruction using bovine pericardium bovine matrix. The procedures were performed by the same surgical team between April 2018 and May 2023.

RESULTS

The rates of early and late complications were examined after a median follow-up period of 30.2 ± 5.5 months. The results revealed that the rates of early complications stood at 9.7%, while late complications were observed in 14.5% of the cases. The most common late complication was seroma formation (7.7%) which six were resolved without any surgical intervention.

CONCLUSION

Tutopatch® can be used as an extension of the muscle to cover the prosthesis. It forms an extra layer over the silicone implant that helps to decrease the complications as capsular contracture and implant exposure. It also represents a significant 85 % reduction in cost when compared to a similar-sized mesh materials.

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 .

Safety and aesthetic outcomes of SERASYNTHⓇ MESH BR for direct-to-implant breast reconstruction: A retrospective single center analysis of 32 consecutive cases

Background

Bilateral mastectomy for both therapeutic and prophylactic reasons is becoming increasingly important. To achieve good results after mastectomy, synthetic meshes are often used as an alternative to acellular dermal matrices (ADMs). The aim of this study is to analyze the results of subcutaneous mastectomies and direct-to-implant breast reconstruction using SERASYNTHⓇ MESH BR.

Methods

In this work, data from mastectomies (n = 32) in 22 patients without prior radiation after breast reconstruction with SERASYNTHⓇ MESH BR from a single center were retrospectively analyzed with 1 year follow-up. Complications were categorized as serious (need for revision surgery) and minor events. Statistical analysis was performed using the t-test in SPSS. Data were compared with the existing literature.

Results

Major complications occurred in 15.6% (n = 5). Two out of five revisions were due to hematoma. In three cases, a seroma followed by other complications (e.g., infections, necrosis) necessitated revision. Minor complications occurred in 12.5% of cases. Due to the safety aspect, implants were replaced in each revision. There was no significant difference in complication rates between prophylactic and therapeutic mastectomies (p = 0.3815, SE = 0.171). There was no statistically significant difference in esthetic outcomes (p = 0.3846).

Conclusion

The application of the absorbable polymer poly-p-dioxanone SERASYNTHⓇ MESH BR has complication rates comparable to those reported in the existing literature. Careful patient selection is paramount in order to limit the complication rate. SERASYNTHⓇ MESH BR can be considered a safe tool to achieve esthetic results in combination with direct-to-implant breast reconstruction.

Comparing the Outcomes and Complication Rates of Biologic vs Synthetic Meshes in Implant-Based Breast Reconstruction: A Systematic Review

OBJECTIVE

This systematic review evaluates all published studies comparing biologic and synthetic meshes in implant-based breast reconstruction (IBBR), to determine which category of mesh produces the most favorable outcomes.

SUMMARY BACKGROUND DATA

Breast cancer is the most common cancer in women globally. Implant-based breast reconstruction is currently the most popular method of postmastectomy reconstruction, and recently, the use of surgical mesh in IBBR has become commonplace. Although there is a long-standing belief among surgeons that biologic mesh is superior to synthetic mesh in terms of surgical complications and patient outcomes, few studies exist to support this claim.

METHODS

A systematic search of the EMBASE, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies comparing biologic and synthetic meshes within the same experimental framework were included. Study quality and bias were assessed using the validated Methodological Index for Non-Randomized Studies criteria.

RESULTS

After duplicate removal, 109 publications were reviewed, with 12 meeting the predetermined inclusion criteria. Outcomes included common surgical complications, histological analysis, interactions with oncologic therapies, quality of life measures, and esthetic outcomes. Across all 12 studies, synthetic meshes were rated as at least equivalent to biologic meshes for every reported outcome. On average, the studies in this review tended to have moderate Methodological Index for Non-Randomized Studies scores.

CONCLUSION

This systematic review offers the first comprehensive evaluation of all publications comparing biologic and synthetic meshes in IBBR. The consistent finding that synthetic meshes are at least equivalent to biologic meshes across a range of clinical outcomes offers a compelling argument in favor of prioritizing the use of synthetic meshes in IBBR.

Impact of demographic and perioperative risk factors on complication rates in skin-sparing/nipple-sparing mastectomy with implant-based reconstruction using titanized polypropylene mesh (TiLOOP® Bra)

BACKGROUND

Skin/nipple-sparing mastectomies (SSM/NSSM) have been reported to have acceptable complication rates and good aesthetic outcomes with high patient satisfaction. However, in this relatively young and rapidly expanding field of reconstructive plastic surgery, differences in perioperative management are noted between breast centers. Prospective studies of complication rates using a titanized polypropylene mesh (TiLOOP® Bra) are currently lacking.

METHODS

A prospective subgroup analysis was performed based on the data set of the prospective, single-arm, multicenter observational study (PRO-BRA). Early complication rates after skin/nipple-sparing mastectomy with implant-based immediate or secondary reconstruction using a titanized polypropylene mesh (TiLOOP® Bra) subpectorally were investigated in relation to demographic factors, as well as intra-and postoperative management. The subgroup consists of 258 patients. Complications were categorised into necrosis, infection, postoperative bleeding or hematoma, seroma, wound healing delays and R1-situations.

RESULTS

Early complication rates of SSM/NSSM using titanium-based meshes are comparable to complication-rates using ADM's. Logistic regression shows significantly higher risk for wound healing delays, necrosis and seroma with increasing BMI, abladat- and implant-weight (OR 1,17 -1,66, p-value < 0,001). Smokers have significantly higher necrosis rates (20.7%) compared to non-smokers (5.5%) (p-value = 0.002). Discharge with drainage results in a trend toward higher rates of wound healing complications.

CONCLUSION

The use of TiLOOP® Bra meshes was shown to have acceptable complication rates. Complication rates depend on certain demographic and intraoperative risk factors and should be considered in indications and information of patients.

Immediate prepectoral implant reconstruction using TiLOOP Bra Pocket results in improved patient satisfaction over dual plane reconstruction

BACKGROUND

Implant-based reconstruction accounts for the majority of breast reconstructive procedures performed in Australia. More recently, immediate prepectoral implant reconstruction using the TiLOOP Bra Pocket has gained popularity. This study compares post-surgical complications and patient-reported quality of life outcomes between immediate prepectoral and dual plane implant reconstruction.

METHODS

A retrospective study of 80 consecutive patients who underwent nipple-sparing mastectomies and immediate implant reconstruction was conducted. Implants were either completely covered with TiLOOP Bra and/or TiLOOP Bra Pocket (pfm medical, Cologne, Germany) and secured in the prepectoral space (prepectoral group) or placed in the subpectoral plane with inferolateral mesh coverage (dual plane group). Data surrounding patient demographics, clinical details and post-surgical outcomes were compared. Patient-related quality of life outcomes were assessed with the Breast-Q questionnaire.

RESULTS

A total of 80 patients (109 breasts) operated on between June 2016 and December 2018 were included. The prepectoral and dual plane groups comprised of 40 patients each, including 50 and 59 operated breasts, respectively. Post-operative complications were comparable with 11 (22%) overall complications in the prepectoral group and eight (14%) in the dual plane group (P = 0.313). Implant loss was uncommon with four (8%) cases in the prepectoral group and five (8.5%) in the dual plane group (P = 0.929). Patient-reported quality of life outcomes were superior after prepectoral reconstruction with patients reporting a significantly higher score in the satisfaction with breasts domain (68.9 versus 57.5; P = 0.036).

CONCLUSION

Immediate prepectoral implant reconstruction with the TiLOOP Bra Pocket was associated with improved patient satisfaction and demonstrated no difference in early post-operative outcomes.

First-year complications after immediate breast reconstruction with a biological and a synthetic mesh in the same patient: A randomized controlled study

Background

Even though meshes and matrices are widely used in breast reconstruction, there is little high‐quality scientific evidence for their risks and benefits. The aim of this study was to compare first‐year surgical complication rates in implant‐based immediate breast reconstruction with a biological mesh with that of a synthetic mesh, in the same patient.

Methods

This study is a clinical, randomized, prospective trial. Patients operated on with bilateral mastectomy and immediate breast reconstruction were randomized to biological mesh on one side and synthetic mesh on the other side.

Results

A total of 48 breasts were randomized. As the synthetically and the biologically reconstructed breasts that were compared belonged to the same woman, systemic factors were exactly the same in the two groups. The most common complication was seroma formation with a frequency of 38% in the biological group and 3.8% in the synthetical group (p = .011). A higher frequency of total implant loss could be seen in the biologic mesh group (8.5% vs. 2%), albeit not statistically significant (p = .083).

Conclusions

In the same patient, a synthetic mesh seems to yield a lower risk for serious complications, such as implant loss, than a biological mesh.