Analysis of Secondary Surgeries after Immediate Breast Reconstruction for Cancer Compared with Risk Reduction

A Single-center Comparison of Surgical Outcomes following Prepectoral and Subpectoral Implant-based Breast Reconstruction

Background

Prepectoral implant placement continues to gain widespread acceptance as a safe and effective option for breast reconstruction. Current literature demonstrates comparable rates of complications and revisions between prepectoral and subpectoral placement; however, these studies are underpowered and lack long-term follow-up.

Methods

We performed a retrospective cohort study of patients who underwent immediate two-staged tissue expander or direct-to-implant breast reconstruction at a single center from January 2017 to March 2021. Cases were divided into prepectoral and subpectoral cohorts. The primary outcomes were postoperative complications, aesthetic deformities, and secondary revisions. Descriptive statistics and multivariable regression models were performed to compare the demographic characteristics and outcomes between the two cohorts.

Results

We identified 996 breasts (570 patients), which were divided into prepectoral (391 breasts) and subpectoral (605 breasts) cohorts. There was a higher rate of complications (P < 0.001) and aesthetic deformities (P = 0.02) with prepectoral breast reconstruction. Secondary revisions were comparable between the two cohorts. Multivariable regression analysis confirmed that prepectoral reconstruction was associated with an increased risk of complications (odds ratio 2.39, P < 0.001) and aesthetic deformities (odds ratio 1.62, P = 0.003).

Conclusions

This study evaluated outcomes in patients undergoing prepectoral or subpectoral breast reconstruction from a single center with long-term follow-up. Prepectoral placement was shown to have an inferior complication and aesthetic profile compared with subpectoral placement, with no difference in secondary revisions. These findings require validation with a well-designed randomized controlled trial to establish best practice for implant-based breast reconstruction.

Characteristics and therapeutic profile of TBI patients who underwent bilateral decompressive craniectomy: experience with 151 cases

BACKGROUND

Decompressive craniectomy (DC) and intracranial pressure (ICP) monitoring are common approaches to reduce the death rate of Traumatic brain injury (TBI) patients, but the outcomes of these patients are unfavorable, particularly those who receive bilateral DC. The authors discuss their experience using ICP and other potential methods to improve the outcomes of TBI patients who receive bilateral DC.

METHODS

Data from TBI patients receiving bilateral DC from Jan. 2008 to Jan. 2022 were collected via a retrospective chart review. Included patients who received unplanned contralateral DC after initial surgery were identified as unplanned secondary surgery (USS) patients. Patients' demographics and baseline medical status; pre-, intra-, and postoperative events; and follow-up visit outcome data were analyzed.

RESULTS

A total of 151 TBI patients were included. Patients who underwent USS experienced more severe outcomes as assessed using the 3-month modified Rankin Scale score (P = 0.024). In bilateral DC TBI patients, USS were associated with worsen outcomes, moreover, ICP monitoring was able to lower their death rate and was associated with a lower USS incidence. In USS patients, ICP monitoring was not associated with improved outcomes but was able to lower their mortality rate (2/19, 10.5%, vs. 10/25, 40.0%; P = 0.042).

CONCLUSION

The avoidance of USS may be associated with improved outcomes of TBI patients who underwent bilateral DC. ICP monitoring was a potential approach to lower USS rate in TBI patients, but its specific benefits were uncertain.

Long-term outcomes of breast reconstruction and the need for revision surgery

BACKGROUND

Breast reconstruction (BR) often forms part of a patient's breast cancer journey. Revision surgery may be required to maintain the integrity of a BR, although this is not commonly reported in the literature. Different reconstructive methods may have differing requirements for revision. It is important for patients and surgeons to understand the factors leading to the need for revision surgery.

METHODS

This retrospective cohort study analyses BRs performed by oncoplastic breast surgeons in public and private settings between 2005 and 2014, with follow-up until December 2018. Surgical and patient factors were examined, including types of BR, complications and reasons for revision surgery.

RESULTS

A total of 390 women with 540 reconstructions were included, with a median follow-up of 61 months. Twenty-eight percent (151/540) of reconstructions required at least one revision operation. Overall, implant-based reconstructions (direct-to-implant [DTI] and two-stage expander-implant) had a higher revision rate compared to pedicled flap reconstructions (odds ratio 1.91, 95% confidence interval 1.08, 3.38). DTI reconstructions had the highest odds, and pedicled flap without implants the lowest odds of requiring revision. Post-reconstruction radiotherapy increased the chance of revision surgery, while pre-reconstruction radiotherapy did not. Odds of revision were higher in implant-based reconstructions compared to pedicled flap reconstructions that had radiotherapy. Other factors increasing the rates of revision surgery were being a current smoker and post-operative infection.

CONCLUSION

Almost one-third of reconstructive patients require revision surgery. Autologous pedicled flap reconstructions have lower rates of revision compared to implant-based reconstructions. Radiotherapy increases the need for revision surgery, particularly in implant-based reconstructions.