Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions

Protective role of transforming growth factor-Β3 (TGF-Β3) in the formation of radiation-induced capsular contracture around a breast implant: In vivo experimental study

Postmastectomy radiotherapy causes capsular contracture due to fibroproliferation of the capsular tissue around the implant. In fibrosis, unlike normal wound healing, structural and functional disorders are observed in the tissues caused by excessive/irregular accumulation of extracellular matrix proteins. It has been reported that transforming growth factor-β3 (TGF-β3) prevents and reverses fibrosis in various tissues or provides scarless healing with its antifibrotic effect. Additionally, TGF-β3 has been shown to reduce fibrosis in radiotherapy-induced fibrosis syndrome. However, no study in the literature investigates the effects of exogenously applied TGF-β3 on capsular contracture in aesthetic or reconstructive breast implant application. TGF-β3, which has a very short half-life, has low bioavailability with parenteral administration. Within the scope of this study, free TGF-β3 was loaded into the nanoparticles to increase its low bioavailability and extend its duration of action by providing controlled release. The aim of this study is to investigate the preventive/improving effects of radiation induced capsular contracture using chitosan film formulations containing TGF-β3 loaded poly(lactic-co-glycolic acid)-b-poly(ethylene glycol) (PLGA-b-PEG) nanoparticles in implant-based breast reconstruction. In the characterization studies of nanoparticles, the particle size and zeta potential of the TGF-β3-loaded PLGA-b-PEG nanoparticle formulation selected to be used in the treatment group were found to be 123.60 ± 2.09 nm and -34.87 ± 1.42 mV, respectively. The encapsulation efficiency of the formulation was calculated as 99.91 %. A controlled release profile was obtained in in vitro release studies. Chitosan film formulations containing free TGF-β3 or TGF-β3-loaded PLGA-b-PEG nanoparticles were used in in vivo studies. In animal studies, rats were randomly distributed into 6 groups (n = 8) as sham, implant, implant + radiotherapy, implant + radiotherapy + chitosan film containing unloaded nanoparticles, implant + radiotherapy + chitosan film containing free TGF-β3, implant + radiotherapy + chitosan film containing TGF-β3 loaded nanoparticle. In all study groups, a 2 cm incision was made along the posterior axillary line at the thoracic vertebral level in rats to reach the lateral edge of the latissimus dorsi. The fascial attachment to the chest wall was then bluntly dissected to create a pocket for the implants. In the treatment groups, the wound was closed after films were placed on the outer surface of the implants. After administering prophylactic antibiotics, rats were subjected to irradiation with 10 Gy photon beams targeted to each implant site. Each implant and the surrounding excised tissue were subjected to the necessary procedures for histological (capsule thickness, cell density), immunohistochemical, and biochemical (α-SMA, vimentin, collagen type I and type III, TGF-β1 and TGF-β3: expression level/protein level) examinations. It was determined that the levels of TGF-β1 and TGF-β3 collagen type III, which decreased as a result of radiotherapy, were brought to the control level with free TGF-β3 film and TGF-β3 nanoparticle film formulations. Histological analyses, consistent with biochemical analyses, showed that thick collagen and fibrosis, which increased with radiotherapy, were brought to the control level with free TGF-β3 film and TGF-β3 nanoparticle film treatments. In biochemical analyses, the decrease in thick collagen was compatible with the decrease in the collagen type I/type III ratio in the free TGF-β3 film and TGF-β3 nanoparticle film groups. Changes in protein expression show that TGF-β3 loaded nanoparticles are more successful than free TGF-β3 in wound healing. In line with these results and the literature, it is thought that the balance of TGF-β1 and TGF-β3 should be maintained to ensure scarless wound healing with no capsule contracture.

Analysis of Factors Affecting the Choice of Implant-based or Autologous Fat Grafting Breast Augmentation: A Retrospective Study

BACKGROUND

Breast augmentation mainly includes implant-based and autologous fat grafting augmentation. Choosing the right surgical method for the patient is particularly important. However, an analysis of the factors that may affect the choice of surgical methods among patients has not yet been performed. In this study, the authors sought to identify the factors that influence the choice of surgical methods for women who receive implant or autologous fat grafting breast augmentation.

METHODS

A total of 192 female patients with micromastia who were hospitalized for breast augmentation from June 2018 to June 2021 were included in the study. The enrolled patients were divided into the implant group (n=92) and the fat group (n=100). Univariate and multivariate analyses were then performed on the data.

RESULTS

In the univariate analysis, there were statistical differences between the implant and fat group in weight, BMI, marital status, occupation, bilateral midsternal line-nipple distance difference, bilateral nipple-inframammary fold distance difference in the natural state, and others ( P <0.05). In the final logistic binary regression analysis, the statistically different factors included the acceptable number of operations, chest circumference through the armpit, and chest circumference through the inframammary fold ( P <0.05).

CONCLUSION

There were several factors, such as acceptable numbers of operations, chest circumference through the armpit, and chest circumference through the inframammary fold, may affect the choice of breast augmentation surgery method for Chinese female patients.

LEVEL OF EVIDENCE

Level-III, retrospective cohort study.

Three-Dimensional Printing in Breast Reconstruction: Current and Promising Applications

Three-dimensional (3D) printing is dramatically improving breast reconstruction by offering customized and precise interventions at various stages of the surgical process. In preoperative planning, 3D imaging techniques, such as computer-aided design, allow the creation of detailed breast models for surgical simulation, optimizing surgical outcomes and reducing complications. During surgery, 3D printing makes it possible to customize implants and precisely shape autologous tissue flaps with customized molds and scaffolds. This not only improves the aesthetic appearance, but also conforms to the patient's natural anatomy. In addition, 3D printed scaffolds facilitate tissue engineering, potentially favoring the development and integration of autologous adipose tissue, thus avoiding implant-related complications. Postoperatively, 3D imaging allows an accurate assessment of breast volume and symmetry, which is crucial in assessing the success of reconstruction. The technology is also a key educational tool, enhancing surgeon training through realistic anatomical models and surgical simulations. As the field evolves, the integration of 3D printing with emerging technologies such as biodegradable materials and advanced imaging promises to further refine breast reconstruction techniques and outcomes. This study aims to explore the various applications of 3D printing in breast reconstruction, addressing current challenges and future opportunities.

Outcomes after elevation of serratus anterior fascia flap versus serratus muscle flap in direct-to-implant breast reconstruction following mastectomy: a prospective study

Objective

The purpose of this study was to compare postoperative pain between SF flap and serratus anterior muscle (SM) in direct-to-implant breast reconstruction.

Methods

This is a prospective cohort study that included 53 women diagnosed with breast cancer who underwent mastectomy and one-stage implant-based breast reconstruction from January 2020 to March 2021. Twenty-nine patients (54.7%) had SF elevation, and 24 patients (45.3%) underwent SM elevation. We evaluated patient-reported early postoperative pain on the first day after surgery. Also, it was reported that all surgical complications in the first month and patient reported outcomes (PROs) were measured with the BRECON 23 questionnaire.

Results

The serratus fascia group used implants with larger volumes, 407.6 ± 98.9 cc (p < 0.01). There was no significant difference between the fascial and muscular groups regarding the postoperative pain score reported by the patients (2 versus 3; p = 0.30). Also, there was no difference between the groups regarding early surgical complications and PROs after breast reconstruction.

Conclusion

The use of SF seems to cause less morbidity, which makes the technique an alternative to be considered in breast reconstruction. Although there was no statistical difference in postoperative pain scores between the fascia and serratus muscle groups.

Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study

Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.

Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Conflicting evidence exists regarding the utility of prophylactic postoperative antibiotics in tissue expander (TE)-based breast reconstruction. This study evaluated the risk of surgical-site infection between patients receiving 24 hours of perioperative antibiotics alone versus prolonged postoperative antibiotics within a propensity score-matched cohort.

METHODS

Patients undergoing TE-based breast reconstruction receiving 24 hours of perioperative antibiotics alone were propensity score-matched 1:3 to patients receiving postoperative antibiotics based on demographics, comorbidities, and treatment factors. Incidence of surgical-site infection was compared based on duration of antibiotic prophylaxis.

RESULTS

Of a total of 431 patients undergoing TE-based breast reconstruction, postoperative antibiotics were prescribed in 77.2%. Within this cohort, 348 were included for propensity matching (no antibiotics, 87 patients; antibiotics, 261 patients). After propensity score matching, there was no significant difference in incidence of infection requiring intravenous (no antibiotics, 6.9%; antibiotics, 4.6%; P = 0.35) or oral antibiotics (no antibiotics, 11.5%; antibiotics, 16.1%; P = 0.16). In addition, rates of unplanned reoperation ( P = 0.88) and 30-day readmission ( P = 0.19) were similar. After multivariate adjustment, prescription of postoperative antibiotics was not associated with a reduction in surgical-site infection (OR, 0.5; 95% CI, -0.3 to 1.3; P = 0.23).

CONCLUSIONS

Within a propensity score-matched cohort accounting for patient comorbidities and receipt of adjuvant therapies, prescription of postoperative antibiotics after TE-based breast reconstruction conferred no improvement in rates of TE infection, reoperation, or unplanned health care use. These data underscore the need for multicenter randomized trials on the utility of antibiotic prophylaxis in TE-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Selective Capsulotomies and Partial Capsulectomy in Implant-Based Breast Reconstruction Revision Surgery

Background

Breast cancer with about 2.3 million diagnoses and 685,000 deaths globally is the most frequent malignancy in the female population. Continuous research has led to oncological and reconstructive advances in the management of breast cancer, thus improving outcomes and decreasing patient morbidity. Nowadays, the submuscular expander and prosthesis (E/P) implant-based breast reconstruction (IBR) accounts for 73% of all reconstructions. Despite its widely accepted efficacy, the technique is not free from complications and up to 28% of cases require revision surgery for mechanical complications such as capsular contracture, implant displacement/rotation, and implant rupture. With this study, the authors report their experience in the management of E/P IBR revision surgery through the technique of Selective Capsulotomies (SCs) and Partial Capsulectomy (PC).

Methods

A retrospective study was conducted on patients who had previously undergone E/P IBR and presented for revision reconstruction between January 2013 and May 2023 at the Department of Plastic Surgery of the University of Siena, Italy. Reasons for revision included capsular contracture, implant displacement/rotation, and implant rupture. Revision reconstructions involved SC and PC with implant replacement. Fat grafting was also considered. The complication rate was evaluated by analysis of patients' medical records. Patients' satisfaction with the treatment was assessed through a specific questionnaire.

Results

32 patients underwent revision surgeries. No early complication occurred. Recurrence rate was assessed at 19% with average follow-up of 59 months (range: 13-114 months). The average time between revision surgery and recurrence was 3 years (range: 1-6 years). 23 patients answered the questionnaire and were overall satisfied with the treatments (8.29/10).

Conclusions

SC possibly associated to PC is a valuable option for E/P IBR revision surgery with minimal complications, reduced surgical trauma, short operating time, and relatively low recurrence risk. In addition, treated patients are overall satisfied with the results over time.

Postmastectomy radiotherapy in breast reconstruction: Current controversies and trends

Breast cancer is the most common cancer among women worldwide. Postmastectomy radiotherapy (PMRT) is an essential component of combined therapy for early-stage, high-risk breast cancer. Breast reconstruction (BR) is often considered for patients with breast cancer who have undergone mastectomy. There has been a considerable amount of discussion about the optimal approach to combining PMRT with BR in the treatment of breast cancer. PMRT may increase the risk of complications and prevent good aesthetic results after BR, while BR may increase the complexity of PMRT and the radiation dose to surrounding normal tissues. The purpose of this review is to give a broad overview and summary of the current controversies and trends in PMRT and BR in the context of the most recent literature available.

Effect of Perioperative Prophylactic Intravenous Antibiotic Use in Immediate Implant-Based Breast Reconstruction: A Retrospective Matched Cohort Study

Background  Among breast reconstruction methods, implant-based breast reconstruction has become the mainstream. However, periprosthetic infection is still an unresolved problem. Although published articles have revealed that limited use of antibiotics is sufficient to reduce infection rates, the number of surgeons still preferring elongated usage of antibiotics is not less. The aim of our study is to validate the appropriate duration of antibiotic use to reduce infection rate after implant-based breast reconstruction. Methods  A retrospective study reviewed medical record of 235 patients (274 implants for reconstruction) who underwent prepectoral direct to implant breast reconstruction using acellular dermal matrix wrapping technique. Infection rates were analyzed for the patients administered postoperative prophylactic antibiotics until drain removal and those who received only perioperative prophylactic antibiotics for 24 hours. Results  Of the 274 implants, 98 who were administered prophylactic antibiotics until drain removal had an infection rate of 3.06% (three implants) and 176 who received prophylactic antibiotics no longer than 24 hours postoperatively had an infection rate of 4.49% (eight implants). A total of 11 patients diagnosed with postoperative infection clinically, 8 were salvaged by antibiotic treatment, and 3 had implant removal and replacement with autologous flap. Postoperative antibiotic prophylaxis duration had no statistically significant effects in the risk of infection ( p  = 0.549). Conclusion  The duration of prophylactic antibiotics after surgery was not related to infection risk. Further study with a large number of patients, randomized control study, and route of antibiotics is needed.

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.

Evaluation of the Artificial Intelligence Chatbot on Breast Reconstruction and Its Efficacy in Surgical Research: A Case Study

BACKGROUND

ChatGPT is an open-source artificial intelligence (AI) chatbot that uses deep learning to produce human-like text dialog. Its potential applications in the scientific community are vast; however, its efficacy on performing comprehensive literature searches, data analysis and report writing in aesthetic plastic surgery topics remains unknown. This study aims to evaluate both the accuracy and comprehensiveness of ChatGPT's responses to assess its suitability for use in aesthetic plastic surgery research.

METHODS

Six questions were prompted to ChatGPT on post-mastectomy breast reconstruction. First two questions focused on the current evidence and options for breast reconstruction post-mastectomy, and remaining four questions focused specifically on autologous breast reconstruction. Using the Likert framework, the responses provided by ChatGPT were qualitatively assessed for accuracy and information content by two specialist plastic surgeons with extensive experience in the field.

RESULTS

ChatGPT provided relevant, accurate information; however, it lacked depth. It could provide no more than a superficial overview in response to more esoteric questions and generated incorrect references. It created non-existent references, cited wrong journal and date, which poses a significant challenge in maintaining academic integrity and caution of its use in academia.

CONCLUSION

While ChatGPT demonstrated proficiency in summarizing existing knowledge, it created fictitious references which poses a significant concern of its use in academia and healthcare. Caution should be exercised in interpreting its responses in the aesthetic plastic surgical field and should only be used for such with sufficient oversight.

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 .

Human-Mimic Submuscular and Premuscular Irradiated Rat Model: Histologic Characteristics of the Capsule Tissue in Contact with the Breast Implant

Background

In this study, we established two rat models that mimic human submuscular and premuscular breast reconstruction. We analyzed the capsule formation according to surgical techniques and adjacent tissues, including the chest wall tissues, such as the ribs and acellular dermal matrices (ADMs) that come in contact with silicone implants.

Methods

This study consisted of experiments on 12 Sprague-Dawley rats that underwent implant reconstruction using ADM. They were divided into two groups: rats that underwent dual-plane implantation (n = 6; group 1) and those that underwent premuscular implant insertion (n = 6; group 2). All rats were irradiated with 35 Gy of fractionated radiation. Three months after surgery, the histology and immunochemistry of the capsule tissues of the ADM, muscle, and chest wall were analyzed.

Results

Overall capsule thickness was thicker in group 1. Based on the tissue in contact with the silicone implant, ADM had a thinner capsule, less inflammation, less fibrosis, and less vascularization than the muscle and chest wall tissues.

Conclusions

This study described two rat models of clinically relevant implant-based breast reconstruction using a submuscular and premuscular plane, ADM, and irradiation. Overall, the premuscular implantation rat model was associated with a thinner capsule. The ADM in contact with the silicone implant, even after irradiation, had superior protection from radiation compared with the other tissues.

A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review

INTRODUCTION

Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study.

METHODS

The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared.

RESULTS

Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05).

CONCLUSION

This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Difference in the Occurrence of Capsular Contracture According to Tissue Characteristics in an Irradiated Rat Model

BACKGROUND

This study was performed to evaluate the hypothesis that capsule formation varies according to the radiation dose in muscle tissues; chest wall tissues, including the ribs; and acellular dermal matrices (ADM) that are in contact with the silicone implant.

METHODS

In this study, 20 Sprague-Dawley rats underwent submuscular plane implant reconstruction using ADM. They were divided into four groups: an unradiated control group ( n = 5), nonfractionated radiation at a dose of 10 Gy ( n = 5), nonfractionated radiation at a dose of 20 Gy ( n = 5), and fractionated radiation at a dose of 35 Gy ( n = 5). Three months after surgery, hardness was measured, and histologic and immunochemical analyses of the capsule tissues of the ADM, muscle tissues, and chest wall tissues were analyzed.

RESULTS

As the radiation dose increased, the silicone implant became harder, but no significant difference in capsule thickness according to the radiation dose was observed. Based on the tissue in contact with the silicone implant, ADM had a thinner capsule thickness than the muscle tissues, as well as less inflammation and less neovascularization compared with the other tissues.

CONCLUSIONS

This study describes a new rat model of clinically relevant implant-based breast reconstruction using a submuscular plane and ADM with irradiation. The ADM in contact with the silicone implant, even after irradiation, was protected from radiation compared with the other tissues.

CLINICAL RELEVANCE STATEMENT

These research results could support the use of ADM in implant-based breast reconstruction for prevention of the capsular contracture, even after radiation.

Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose?

Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.

Immediate Breast Reconstruction After Neoadjuvant Chemotherapy: Factors Associated With Surgical Selection and Complications

BACKGROUND

Breast reconstruction has become an integral component of breast cancer treatment, especially for patients who are unable to undergo breast-conserving surgery after neoadjuvant chemotherapy (NAC). We analyzed factors influencing the type of immediate reconstruction surgery after NAC, as well as the complication rates for each surgery type.

METHODS

The study included patients with breast cancer who underwent mastectomy following NAC from 2010 to 2021. Clinicopathological characteristics, unplanned reoperation rates, and the duration of postoperative hospitalization were analyzed in patients undergoing autologous tissue reconstruction (ATR, n = 127), implant-based reconstruction (IBR, n = 60), and combined autologous tissue and implant reconstruction (n = 60).

RESULTS

A total of 1651 patients who received NAC before mastectomy were enrolled. Among them, 247 (15.0%) patients underwent immediate reconstruction (IR), whereas 1404 underwent mastectomy only. Patients in the IR group were younger ( P < 0.001), had lower body mass index ( P < 0.001), and exhibited earlier clinical ( P = 0.003) and nodal ( P < 0.001) stage than those in the non-IR group. Patients in the ATR group were older ( P < 0.001) and had higher body mass index ( P = 0.007), larger tumor size ( P = 0.024), and more frequent childbearing history ( P = 0.011) than those in the other groups. Complications resulting in unplanned reoperations were more frequent in the IBR group ( P = 0.039). The duration of postoperative hospitalization was longest after ATR ( P = 0.008).

CONCLUSIONS

Age and clinical tumor/nodal stage at presentation are associated with IR for patients undergoing mastectomy after NAC. For patients undergoing IR after NAC, ATR may be safer and more suitable than IBR.

Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database

INTRODUCTION

Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay.

METHODS

The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05.

RESULTS

A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001).

CONCLUSION

National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.

Multiple uptake of 99mTc-MDP in chest due to breast implant rupture in a patient with lung adenocarcinoma

A 57-year-old woman was diagnosed as lung adenocarcinoma. 99mTc-MDP bone scan showed multiple radioactivity concentrated lesions on bilateral chest wall, which were confirmed as calcification foci after breast implant rupture by SPECT/CT. SPECT/CT could be used for differential diagnosis of breast implant rupture and malignant lesions.

Assessment, Complications, and Surveillance of Breast Implants: Making Sense of 2022 FDA Breast Implant Guidance

As more information about the potential risks and complications related to breast implants has become available, the United States Food and Drug Administration (FDA) has responded by implementing changes to improve patient education, recalling certain devices and updating the recommendations for screening for silicone implant rupture. In addition to staying up-to-date with FDA actions and guidance, radiologists need to maintain awareness about the types of implants they may see, breast reconstruction techniques including the use of acellular dermal matrix, and the multimodality imaging of implants and their complications. Radiologists should also be familiar with some key differences between the updated FDA guidelines for implant screening and the imaging recommendations from the American College of Radiology Appropriateness Criteria. The addition of US as an acceptable screening exam for silicone implant rupture by the FDA is one of the most notable changes that has potentially significant implications.

Postmastectomy breast reconstruction for women with hereditary gastric and breast cancer syndrome

Post mastectomy reconstruction is nowadays an integral part of breast cancer treatment, usually performed in the immediate setting. Among women with hereditary gastric and breast cancer syndromes, three different scenarios can be identified. First, healthy women seeking for prophylactic mastectomies. Second, cancer patients requiring mastectomy at the tumor site and simultaneous risk reducing mastectomy of the healthy breast. Third, cancer patients who have been treated for primary cancer requiring risk reducing mastectomies in a further stage. In this paper, we present a schematic guide for reconstruction for each subpopulation of subjects and their peculiarities.

Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio

We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast).

BACKGROUND

The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction.

METHODS

We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data.

RESULTS

The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).

The Impact of Postmastectomy Radiation Therapy on the Outcomes of Prepectoral Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Breast reconstruction is the mainstay treatment choice for patients subjected to a mastectomy. Prepectoral implant-based breast reconstruction (IBBR) is deemed to be a promising alternative to subpectoral reconstruction. Postmastectomy radiation therapy (PMRT) is necessary for locoregional recurrence control and to improve the disease-free survival rate in locally advanced breast cancer. This systematic review and meta-analysis study was designed to reveal the surgical, aesthetic, and oncological outcomes of prepectoral IBBR after PMRT.

METHODS

An extensive literature search was performed from inception to March 28, 2022. All clinical studies that included patients who were subjected to prepectoral IBBR and PMRT were included. Studies that included patients who received radiation therapy before prepectoral IBBR were excluded.

RESULTS

This systematic review included six articles encompassing 1234 reconstructed breasts. Of them, 391 breasts were subjected to PMRT, while 843 breasts were not subjected. Irradiated breasts were more susceptible to develop wound infection (RR 2.49; 95% 1.43, 4.35; P = 0.001) and capsular contracture (RR 5.17; 95% 1.93, 13.80; P = 0.001) than the non-irradiated breasts. Furthermore, irradiated breasts were more vulnerable to losing implants (RR 2.89; 95% 1.30, 6.39; P = 0.009) than the non-irradiated breast. There was no significant difference between both groups regarding the risk of implant extrusion (RR 1.88; 95% 0.20, 17.63; P = 0.58).

CONCLUSIONS

Patients with prepectorally IBBR and PMRT were more vulnerable to developing poor outcomes. This included a higher risk of breast-related and implant-related adverse events.

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 .

The Impact of Aeroform Tissue Expanders on the Outcomes of Implant-Based Breast Reconstruction; A Systematic Review and Meta-Analysis

BACKGROUND

Breast reconstruction can improve the quality of patients' lives by restoring the breasts' natural appearance. Saline-based tissue expanders are associated with significant drawbacks. The current systematic review and meta-analysis aimed to reveal the usability, safety, and economic burden of AeroForm-based tissue expanders for breast reconstruction.

METHODS

An extensive systematic literature review was implemented from inception to 9 December 2021. All clinical studies that included women with breast cancer subjected to AeroForm-based tissue expansion for breast reconstruction were included in the study.

RESULTS

This systematic review included eleven articles consisting of 748 patients. There were 1220 reconstructed breasts in which 530 (43.44%) breasts were reconstructed using AeroForm devices. AeroForm-based tissue expanders were associated with shorter duration to complete breast expansion (MD-35.22; 95% -46.65, -23.78;P<0.001) and complete reconstruction (MD-30.511; 95% -54.659, -6.636;P=0.013). The overall satisfaction rate of the aesthetic results of the AeroForm expanders was 81.4% (95%CI; 60.3% to 92.6%,P=0.006) and 64.6% (95%CI; 53.8% to 74%,P=0.008) for patients and surgeons. Patients subjected to saline-based breast reconstruction were 1.17 times at high risk to develop breast-related adverse events (RR1.17; 95% 0.86, 1.58; P=0.31). This includes a high risk of mastectomy flap necrosis (RR1.91; 95% 1.03, 3.55;P=0.04) and post-operative wound infection (RR 1.63; 95% 0.91, 2.91;P=0.1).

CONCLUSION

AeroForm-based tissue expanders represent a new era of breast reconstruction. These devices provided an earlier transition to exchange for the permanent implant with a convenient and comfortable expansion process. This was associated with a high satisfaction rate for patients and surgeons.

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 .

The influence of synthetic and biologic matrices on the choice of the implant plane during breast reconstruction. The modern state of the problem

Immediately after silicone implants were described, the technique of prepectoral implant placement dominated in breast reconstructive surgery. However, this plane soon had to be abandoned due to the high frequency of complications, such as infection, capsular contracture, explantation. For these reasons, surgeons soon had to switch to the subpectoral plane. Several decades later, thanks to the discovery of synthetic and biological meshes, surgeons returned to the prepectoral plane, but at a technically new level.

The purpose of this review was to analyze the role of biological and synthetic matrices as factors influencing the choice of the implant plane in one-stage breast reconstruction.

Braxon®-assisted prepectoral breast reconstruction: A decade later

We are sitting on the cusp of the bioengineered breast era, in which implant-based breast reconstruction is seeing a growing trend and biotechnology research progressively empowers clinical practice. As never before, the choice of biomaterials has acquired great importance for achieving reconstructive outcomes, and the increase in the use of acellular dermal matrices (ADMs) in the field of senology tells us a story of profound upheaval and progress. With the advent of prepectoral breast reconstruction (PPBR), plenty of devices have been proposed to wrap the silicone prosthesis, either completely or partially. However, this has caused a great deal of confusion and dissent with regard to the adoption of feasible reconstructive strategies as well as the original scientific rationale underlying the prepectoral approach. Braxon^® is the very first device that made prepectoral implant positioning possible, wrapping around the prosthesis and exerting the proven ADM regenerative potential at the implant–tissue interface, taking advantage of the body's physiological healing mechanisms. To date, the Braxon^® method is among the most studied and practiced worldwide, and more than 50 publications confirm the superior performance of the device in the most varied clinical scenarios. However, a comprehensive record of the working of this pioneering device is still missing. Therefore, our aim with this review is to lay a structured knowledge of surgery with BRAXON^® and to provide a decision-making tool in the field of PPBR through a complete understanding on the very first device for prepectoral, one decade after its introduction.

Simultaneous Contralateral Autologous Breast Augmentation during Unilateral Breast Reconstruction Utilizing Deep Inferior Epigastric Flaps

It is predicted that 281,550 new cases of invasive breast cancer and 49,290 new cases of ductal carcinoma in situ will be diagnosed this year. In this study, we will detail our experience with simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral deep inferior epigastric perforator (DIEP) flaps.

Methods

A retrospective analysis of patients who underwent simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral DIEP flaps by the senior surgeons at Beaumont Health Systems, Royal Oak, was conducted. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively analyzed.

Results

Seven patients who met the inclusion criteria were identified. One patient underwent immediate reconstruction with DIEP flaps, one patient had a history of lumpectomy and underwent delayed partial breast reconstruction, three patients had delayed unilateral DIEP breast reconstruction with contralateral breast augmentation, and two patients had previous augmentations that were revised. All patients examined in this review tolerated the procedures well and had clinically viable flaps along with superior aesthetic outcomes.

Conclusions

This technique can be applied to various clinical conditions, including immediate breast reconstruction, delayed breast reconstruction, and salvage for failed implant-based reconstruction, leading to optimal patient outcomes and satisfaction. Unilateral breast reconstruction with simultaneous contralateral autologous breast augmentation utilizing bilateral DIEP flaps is a surgical technique that more plastic surgeons should utilize.

Impact of Dermal Matrix Brand in Implant-Based Breast Reconstruction Outcomes

BACKGROUND

Implant-based reconstruction is the most common procedure for breast reconstruction after mastectomy. Acellular dermal matrix is used to provide additional coverage in subpectoral and prepectoral implant placement. In this study, the authors compared postoperative outcomes between AlloDerm (LifeCell, Branchburg, N.J.) and DermACELL (Stryker, Kalamazoo, Mich.), two acellular dermal matrix brands.

METHODS

A retrospective review of implant-based breast reconstruction from 2016 to 2020 was conducted. Patient demographics and comorbidities, implant size and location, acellular dermal matrix choice, and postoperative outcomes were recorded. Primary outcomes assessed were seroma and infection compared between two acellular dermal matrix brands. Independent clinical parameters were assessed with multiple logistic regression models for the primary outcomes.

RESULTS

Reconstruction was performed in 150 patients (241 breasts). Eighty-eight patients underwent expander placement with AlloDerm and 62 patients with DermACELL. There were no significant differences in patient characteristics between the two groups. There was a significantly higher incidence of seroma in the AlloDerm group in univariate (AlloDerm 21.7 percent versus DermACELL 8.2 percent, p < 0.005) and multivariate analyses ( p = 0.04; 95 percent CI, 1.02 to 6.07). Acellular dermal matrix use (regardless of type) was not associated with higher rates of infection ( p = 0.99), but body mass index was ( p = 0.004).

CONCLUSIONS

Both AlloDerm and DermACELL had similar infection rates regardless of contributing risk factors. AlloDerm was found to be a risk factor for seroma formation in the postoperative period. As such, it is important to be aware of this complication when performing implant-based reconstruction with this brand of acellular dermal matrix.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Prediction of Implant Size Based on Breast Volume Using Mammography with Fully Automated Measurements and Breast MRI

BACKGROUND

Determination of implant size is crucial for patients with breast cancer undergoing one-stage breast reconstruction. The purpose of this study is to predict the implant size based on the breast volume measured by mammography (MG) with a fully automated method, and by breast magnetic resonance imaging (MRI) with a semi-automated method, in breast cancer patients with direct-to-implant reconstruction.

PATIENTS AND METHODS

This retrospective study included 84 patients with breast cancer who underwent direct-to-implant reconstruction after nipple-sparing or skin-sparing mastectomy and preoperative MG and MRI between April 2015 and April 2019. Breast volume was measured using (a) MG with a fully automated commercial software and (b) MRI with an in-house semi-automated software program. Multivariable regression analyses including breast volume and patient weight (P < 0.05 in univariable analysis) were conducted to predict implant size.

RESULTS

MG and MRI breast volume was highly correlated with both implant size (correlation coefficient 0.862 and 0.867, respectively; P values < 0.001) and specimen weight (correlation coefficient 0.802 and 0.852, respectively; P values < 0.001). Mean absolute difference between the MR breast volume and implant size was 160 cc, which was significantly higher than that between the MG breast volume and implant size of 118 cc (P < 0.001). On multivariable analyses, only breast volume measured by both MG and MRI was significantly associated with implant size in any implant type (all P values < 0.001).

CONCLUSION

Breast volume measured by MG and MRI can be used to predict appropriate implant size in breast cancer patients undergoing direct-to-implant reconstruction in an efficient and objective manner.

The Impact of a Single Dual-Trained Surgeon in the Management of Mastectomy and Reconstruction

BACKGROUND

Oncoplastic breast surgery is typically performed using a two-surgeon, two-team approach. The authors present their experience with patients undergoing mastectomy and immediate reconstruction performed by a single, dual-trained breast surgical oncologist and plastic and reconstructive microsurgeon.

METHODS

Patients who underwent mastectomy and/or immediate reconstruction performed by the senior author between 2015 and 2019 were divided into single-surgeon or dual-surgeon cohorts, and matched by age, body mass index, reconstruction type, and cancer stage.

RESULTS

The authors included 158 patients in their analysis (single-surgeon, n = 45; dual-surgeon, n = 113). Single-surgeon patients underwent surgery 13.2 days earlier than single-surgeon patients (p < 0.01), and required significantly fewer preoperative (1.9 versus 3.4; p < 0.01) and postoperative visits (6.8 versus 10.7; p < 0.01). Operative duration was comparable (single-surgeon, 245 minutes; dual-surgeon, 245 minutes; p = 0.99). The authors found no significant difference in surgical-site infection, seroma, hematoma, abdominal donor-site healing, or flap and prosthesis loss between the groups. The authors did find that dual-surgeon patients had a significantly higher rate of mastectomy flap necrosis (20 percent versus 4 percent; p = 0.01), which held true on logistic regression when controlling for other variables. BREAST-Q data demonstrated that single-surgeon patients had significantly higher overall scores (p = 0.04), and were significantly more satisfied with their outcomes, surgeon, and the information provided (p = 0.03, p = 0.03, and p = 0.01, respectively).

CONCLUSIONS

The single-surgeon approach has the potential to decrease patient burden by requiring fewer preoperative and postoperative visits without compromising surgical outcomes or oncologic safety. Further investigation is warranted into the financial implications and patient outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Implants and Breast Pocket Irrigation: Outcomes of Antibiotic, Antiseptic, and Saline Irrigation

BACKGROUND

Breast implant-associated infection and capsular contracture are challenging complications that can result in poor outcomes following implant-based breast surgery. Antimicrobial irrigation of the breast pocket or implant is a widely accepted strategy to prevent these complications, but the literature lacks an evidence-based consensus on the optimal irrigation solution.

OBJECTIVES

The objective of this systematic review was to compare clinical outcomes, specifically capsular contracture, infection, and reoperation rates, associated with the use of antibiotic, antiseptic, and saline irrigation.

METHODS

A systematic review was performed in March 2020 based on the following search terms: "breast implant," "irrigation," "antibiotic," "bacitracin," "antiseptic," "povidone iodine," "betadine," "low concentration chlorhexidine," and "hypochlorous acid." Capsular contracture, infection, and reoperation rates were compared by analysis of forest plots.

RESULTS

Out of the 104 articles screened, 14 met the inclusion criteria. There was no significant difference in capsular contracture rates between antibiotic and povidone-iodine irrigation, although the data comparing these 2 groups were limited and confounded by the concurrent use of steroids. Antibiotic irrigation showed a significantly lower rate of capsular contracture compared with saline irrigation and a lower rate of capsular contracture and reoperation compared with no irrigation at all. Povidone-iodine was associated with lower rates of capsular contracture and reoperation compared with saline irrigation but there were no data on infection rates specific to povidone-iodine irrigation.

CONCLUSIONS

Our study supports the use of antibiotics or povidone-iodine for breast implant irrigation. Further research is required to better determine which of these 2 irrigation types is superior.

LEVEL OF EVIDENCE: 4

≠Risk of breast implant removal after one- versus two-stage breast reconstructive surgery

BACKGROUND

To date, both one- and two-stage techniques are used in immediate 'implant-based breast reconstruction' (IBBR) after mastectomy. Because it is still unknown what technique offers the best clinical outcomes, a multicenter retrospective study was conducted to compare both breast reconstruction techniques.

METHODS

All patients, who underwent a mastectomy followed by immediate one- or two-stage IBBR during 2010 - 2016 were included. Our primary outcome measure was explantation of the 'tissue expander' (TE) and/ or implants within 60 days after breast reconstruction. Secondary outcomes were overall complication rate and secondary corrections.

FINDINGS

Among a total of 383 women, TE/ implant explantation rate was higher in one-stage (19.9%) than in two-stage (11.3%) treated patients (p = 0.082). Overall complication rate (35.7% and 19.9% respectively, p = 0.008) and secondary corrections (29.8% and 20.3% respectively, p = 0.156) were also higher in one-stage compared to two-stage IBBR respectively. However, explantation (OR = 1.55; 95%CI = 0.67-3.58, p = 0.301) and complication (OR = 1.85; 95%CI = 0.92-3.37, p = 0.084) rates were comparable in one- and two-stage IBBR in our stratified multivariate logistic regression analyses, when controlling for history of smoking, nipple-sparing mastectomy, neoadjuvant radiation therapy, and removed breast tissue weight. A remarkable outcome in this study is that women treated with prophylactic surgery were more likely to have an explantation of the TE/ implant after a one-stage IBBR (OR = 4.49; 95%CI = 1.10-18.3, p = 0.037) than two-stage IBBR. In contrast, no association between type of IBBR and risk of TE/implants removal was found among women with a therapeutic mastectomy (OR = 0.82; 95%CI = 0.24-2.79, p =  = 0.74).

CONCLUSION

One- and two-stage IBBR showed a comparable explantation and complication rate in our retrospective study. In one-stage IBBR more secondary corrections were detected. In addition, women who have to decide on a prophylactic mastectomy should be aware of a significantly higher risk of explantation of their implant after one-stage IBBR.

Immediate direct-to-implant breast reconstruction with acellular dermal matrix: Evaluation of complications and safety

OBJECTIVE

Immediate direct-to-implant breast reconstruction with acellular dermal matrix (ADM) is the method of choice for many plastic surgeons and patients, but the use of ADM remains a controversial subject in the literature. This study aimed to investigate complications, reconstructive failure and possible risk factors in direct-to-implant breast reconstruction with ADM (primarily Strattice™).

METHODS

We retrospectively examined all patients undergoing immediate direct-to-implant breast reconstruction with ADM, during a five-year period (2014-2019) at a university clinic. Study outcomes were all complications and explantations. Complications were stratified within and after 6 months postoperatively and subcategorized by type of intervention. Explantations were subcategorized into loss of implant or salvage with immediate insertion of a tissue expander, the same or a new implant.

RESULTS

We included 154 patients and 232 breasts. Complications within 6 months per patient included hematoma (4%), seroma (8%), infection (9%), necrosis, wound dehiscence and delayed wound healing (19%). The total complication rate per patient was 34%. Explantation occurred in 20 patients (13%) of which 9 (6% of all) had implant loss. Preoperative radiotherapy was a significant predictor of explantation (adjusted OR 4.9, 95% confidence interval (CI), 1.0-23.5; p = 0.045), and smoking was also associated with risk of explantation, although only borderline significant (adjusted OR 4.0, 95% CI, 1.0-15.8; p = 0.050).

CONCLUSION

This study demonstrates acceptable rates of re-operations and implant loss compared to other studies but highlights the importance of proper patient selection with regards to risk factors to minimize complications.

Current Challenges in Breast Implantation

Breast implantation (BI) is the most common plastic surgery worldwide performed among women. Generally, BI is performed both in aesthetic and oncoplastic procedures. Recently, the prevalence of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) or breast implant illness (BII) has aroused concerns. As a result, several countries, like Australia, Korea or the United Kingdom, introduced national registries dedicated to the safety and quality of BI surgeries. This narrative review aimed to focus on the clinical challenges, management and the current state of knowledge of BI. Both short and long-term outcomes of BI are determined by various alternatives and differences, which surgeons must consider during the planning and performing breast augmentation along with further complications or risk of reoperation. Proper preoperative decisions and aspects of surgical technique emerged to be equally important. The number of performed breast reconstructions is increasing, providing the finest aesthetic results and improving patient’s quality of life. Choice of prosthesis varies according to individual preferences and anatomical variables. A newly diagnosed cases of BIA-ALCL with lacking data on prevention, diagnosis, and treatment are placing it as a compelling medical challenge. Similarly, BII remains one of the most controversial subjects in reconstructive breast surgery due to unspecified diagnostic procedures, and recommendations.

Breast reconstruction during the COVID-19 pandemic in resource-limited settings

The coronavirus disease 2019 (COVID-19) is a novel, rapidly changing pandemic. It has affected specialized medical services in unprecedented ways. Surgical decision making, always the most important aspect of care has taken on an added layer of complexity in the face of the COVID-19 pandemic. Therefore, recommendations for breast reconstruction during COVID-19 remain challenging and unclear. This article reviews the impact of the COVID-19 pandemic and suggests potential approaches that could be considered in the absence of validated strategies in breast reconstruction.

Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts

Large and/or ptotic breasts demonstrate significant difficulty in breast reconstruction and that the rates of perioperative complications are higher compared with the general population. The authors aim to clarify some details on their previously published technique on skin reducing mastectomy and prepectoral ADM breast reconstruction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Reconstruction and Nipple-Sparing Mastectomy: Technical Modifications and Their Outcomes Over Time at an Academic Breast Center

BACKGROUND

Superior aesthetic outcomes can be achieved with mastectomy techniques that maximize breast envelope preservation and maintain the nipple-areolar complex. This is the impetus for the popularization of the nipple-sparing mastectomy (NSM). Nipple-sparing mastectomy is a challenging procedure due to potential ischemia of the mastectomy flap (which includes the nipple-areolar complex) and the risk of incomplete oncologic resection. We review our experience with NSM, identify technique modifications used over time, and evaluate reconstructive outcomes of NSM and its modifications.

METHODS

A retrospective review of consecutive patients with NSM and breast reconstruction over an 8-year period was completed.

RESULTS

Fifty-five patients underwent 95 NSMs. Indications included invasive and in situ cancer, atypical ductal hyperplasia, and risk reduction. In the first 4 years of experience, the most frequently used NSM incision was radial (lateral) whereas use of a variety of incision patterns was noted in the second 4 years. Overall NSM and breast reconstruction complication rate for the entire study period was 50.9% and included a full-thickness mastectomy skin flap necrosis/nipple necrosis rate of 8.4%. In situ cancer of the nipple was identified in 3.2% of the patients, and 1 patient had locoregional recurrence. Overall complication rate was lower in the second 4 years of experience with NSM and reconstruction. One third of the patients underwent intraoperative fluorescent angiography (FA) to assess mastectomy skin perfusion before reconstruction start. Of the patients who had FA due to perfusion concerns, more than 70% of studies demonstrated poor perfusion and 83.3% of these patients had reconstruction delayed based on these results. Immediate, implant-based reconstruction was performed most commonly. An average of 2.66 procedures were required to achieve reconstruction completion, and 92.4% of the patients who sought reconstruction achieved completion.

CONCLUSIONS

At our institution, NSM use is increasing, NSM incision pattern types used are expanding, and complication rates are decreasing. Immediate, implant-based reconstruction is most commonly used in combination with NSM at our institution. Fluorescent angiography is used to assess mastectomy skin perfusion and likely limits mastectomy complication effects on reconstruction. Despite the occurrence of complications, most patients will complete the breast reconstruction process.

Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review

Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.

Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia

OBJECTIVES

Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia.

MATERIALS AND METHODS

Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed.

RESULTS

Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%).

CONCLUSION

The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.

Prophylactic antibiotic use in acellular dermal matrix-assisted implant-based breast reconstruction

BACKGROUND

Prophylactic antibiotics are used in acellular dermal matrix-assisted implant-based breast reconstructions. However, there are no universally accepted guidelines regarding the best regimen. This retrospective, multicentre study was designed to compare the different prophylactic antibiotic regimens in these patients in three hospitals across two NHS trusts over a five-year period.

METHODS

Case notes and electronic records were reviewed for all patients undergoing acellular dermal matrix-assisted implant-based breast reconstructions between January 2010 and December 2014. Prophylactic antibiotic regimens, duration of use, wound infection, implant loss, seroma and therapeutic antibiotic use was recorded. Patients were divided into groups based on prophylactic antibiotic regimen and actual duration of use. Intergroup analysis was performed using Stata 13.0. Implant loss due to infection was the primary outcome measure.

RESULTS

A total of 105 patients had 122 breast reconstructions performed over the study period. Four prophylactic antibiotic regimens were identified: single dose (n = 20), three doses (n = 17), antibiotics for five-seven days (n = 51) and antibiotics until drains removed (n = 32). There was no statistically significant difference (p > 0.05) between the various regimens in implant loss, wound infection, therapeutic antibiotic prescription or seroma rates. Based on the actual duration of prophylactic antibiotics usage, three groups were identified: prophylactic antibiotics given for one day (n = 26), antibiotics for up to one week (n = 76) and for more than one week (n = 13). Again, no statistically significant difference was observed in the groups for any outcome measure.

CONCLUSION

The study demonstrated no difference in outcomes between different prophylactic antibiotic regimens in acellular dermal matrix-assisted implant-based breast reconstructions.

Applications of 3D printing in breast cancer management

Three-dimensional (3D) printing is a method by which two-dimensional (2D) virtual data is converted to 3D objects by depositing various raw materials into successive layers. Even though the technology was invented almost 40 years ago, a rapid expansion in medical applications of 3D printing has only been observed in the last few years. 3D printing has been applied in almost every subspecialty of medicine for pre-surgical planning, production of patient-specific surgical devices, simulation, and training. While there are multiple review articles describing utilization of 3D printing in various disciplines, there is paucity of literature addressing applications of 3D printing in breast cancer management. Herein, we review the current applications of 3D printing in breast cancer management and discuss the potential impact on future practices.

Ultrastructural features of the double capsulated connective tissue around silicone prostheses

The implantation of breast prostheses for both aesthetic and reconstructive purposes has been growing exponentially in the last 20 years. Safety and prosthesis lifespan are majorly debated issues in relation to the correlated long-term complications. Mainly the periprosthetic capsule that develops around the implant is often the cause of complications and particularly for macrotextured silicone breast implants. Some reports have tried to elucidate the mechanism by which macrotextured silicone implants undergo damage and cause double capsule formation. In this study, we investigated the morphological characteristics of double capsule of macrotextured implants surgically removed from patients. With the use of microscopy techniques, this work analyzed the newly formed tissue observed in the interaction between synthetic and biological surfaces.

Breast Implants for Mammaplasty: An Umbrella Review of Meta-analyses of Multiple Complications

BACKGROUND

The association of breast implants and complications after mammaplasty has been extensively researched. The aim of this study is to summarize all available results in meta-analysis investigating the association between implants and the incidence of various complications.

METHODS

An umbrella review for breast implants and associated complications was performed by searching related reviews from electronic databases including Pubmed, Ovid and CINAHL. We collected and reviewed evidence across meta-analyses of observational and interventional studies of implants and any health outcome. The quality of the reviews was assessed using the AMSTAR tool (A measurement tool to assess systematic reviews).

RESULTS

The research included 92 meta-analyses of 609 studies concerning various areas. Capsular contracture was the most investigated outcome. Radiotherapy, human acellular dermal matrix application, direct-to-implant reconstruction, smooth implant, silicone-filled implant and periareolar incision were significantly associated with higher rates of some of the complications.

CONCLUSIONS

This umbrella review provides surgeons with summarized evidence of the association between the complications and implant-related factors in mammaplasty surgery to help surgeons make informed choices in the future.

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 .

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Retrospective multicenter cohort analysis of 621 cases of BellaGel silicone breast implants with study of physicochemical properties and surface topography

This study aimed to assess the effectiveness and safety of BellaGel implants after implantation in Asian women and inform surgeons of another option for use in breast augmentation and reconstruction. This study was conducted in eight hospitals from November 27, 2015 to April 30, 2018. All patients underwent augmentation mammoplasty or implant-based breast reconstruction with BellaGel implants. Complication rates were compared between groups, and the cumulative hazard function was compared using the Kaplan-Meier survival analysis. Implants were grouped by surface type, and the cumulative hazard functions of total complication cases were compared. The biomechanical properties of the BellaGel implant and other company representative implants were tested using a mechanical testing machine, and surface topography was analyzed using a 3D laser scanning confocal microscope. There was a significant difference in the incidence of complications between the reconstruction (17.1%) and augmentation (4.7%) groups, but no significant difference in the complication rates of each group. There was no difference in the reoperation or revision rates between the groups. The log rank test showed a statistically significant difference in cumulative hazard function between the groups. Among the three types of implants (smooth, textured, and microtextured), the microtextured type had the lowest complication rate. The BellaGel microtexture implant had the highest maximal tensile load and displacement value. The BellaGel and Silksurface implants had the highest stored energy, although there was no significant difference. BellaGel implants can serve as a criterion for the selection of safe and effective implants among currently available implants.