A paradigm shift in U.S. Breast reconstruction: increasing implant rates

Revisiting low complications of VICRYL mesh in breast reconstruction: Insights from an updated systematic review

Background

Alloplastic breast reconstruction continues to be the most prevalent breast reconstruction performed in the United States. Plastic surgeons are challenged to recreate the breast footprint after the ablative surgeon's mastectomy. Mesh augmentation has emerged as a valuable tool in controlling implant migration. Several soft tissue support breast meshes have been introduced, each characterized by a different risk profile, cost, and associated complications.

Objectives

This manuscript presents a comprehensive systematic review, with updated data over the last decade, of the use of a resorbable and less costly VICRYL (Ethicon, Somerville, NJ, USA) mesh in breast reconstruction after mastectomy.

Methods

The authors conducted a systematic review of the use of VICRYL mesh in breast reconstruction using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors queried five databases. Data was collected using a standardized form and underwent review using set inclusion and exclusion criteria. The primary outcome variable was reconstructive failure, with secondary outcomes including seroma, hematoma, skin necrosis, and infection.

Results

A total of 693 articles were found after the multi database search. Forty articles met inclusion criteria. Following full text review, six articles analyzing 511patients were included. VICRYL mesh was utilized in 711 breast reconstructions, of which 5% were complicated by reconstructive failure (confidence interval (CI): 4.75-5.25%); 1.6% by seroma (CI: 1.53-1.67%); 3.33% by infection (CI: 3.14-3.52%); 1.83% by hematoma (CI: 1.71-1.95%); and 6.33% by skin necrosis (CI: 6.03-6.63%).

Conclusion

VICRYL mesh repeatedly demonstrates low reconstructive failure in breast reconstruction with an acceptable complication profile.

Two-stage prepectoral breast reconstruction: A comprehensive review and meta-analysis

BACKGROUND

Implant-based breast reconstruction is the most used approach for breast reconstruction following mastectomy. Prosthetic breast reconstruction helps achieve optimal results with reduced operation time, offering advantages over direct-to-implant and subpectoral reconstruction in selected patients. This study aimed to provide a comprehensive overview of the two-stage prepectoral breast reconstruction.

METHODS

A systematic literature search was performed, and the search was conducted across the PubMed, Cochrane, and Embase databases by adhering to the preferred reporting items for systematic reviews and meta-analysis guidelines. The inclusion criteria encompassed clinical trials or randomized clinical trials related to completed two-stage prepectoral breast reconstruction. Statistical analyses were conducted to synthesize the data and evaluate outcomes.

RESULTS

A total of 48 articles were included for analysis, evaluating 4461 patients and 3894 breasts. The most commonly performed mastectomy type was skin-sparing mastectomy, followed by nipple-areola complex-sparing mastectomy. For the first surgical step, the mean tissue expander size was 423.64 cc, with a mean final expander fill of 349.10 cc. The mean time between the first and second surgery stages was 6.21 months, and the mean follow-up time was 17.10 months. A total of 21.27% of the patients experienced at least one complication. Specifically, seroma was identified in 11.19%, infection in 8.97%, skin flap necrosis in 8.48%, capsular contracture in 6.74%, rippling/wrinkling in 11.30%, expander or implant exposure in 2.38%, and implant removal in 8.62% of the patients.

CONCLUSIONS

Two-stage prepectoral breast reconstruction is a viable surgical option for selected patients. The most frequent complication was seroma. Adjuvant radiotherapy was associated with a higher rate of infection and implant removal.

Why is Volumetric Modulated Arc Therapy Not Considered the Standard of Care for Locoregional Radiation Therapy for Breast Cancer Patients?

We quantify dosimetric differences between 3-dimensional (3D) planning and volumetric modulated arc therapy (VMAT) in breast cancer patients requiring comprehensive regional nodal irradiation (CRNI). Target volume dose, prescription isodose conformality to target volumes, plan hotspots, normal tissue dose-volume metrics, and back and shoulder dose were compared for VMAT and 3D plans of 50 patients. Metrics used to compare VMAT plans with 3D plans included the percentage of primary clinical target volumes (CTVs) receiving 98% of a prescription dose of 5000 cGy, CTV dose hotspots, the extra treatment volume (ETV), and the portion of the patient's body receiving 90% of the CTV prescription dose (excluding the primary target volume). Superior values for these metrics were found for VMAT plans when compared to 3D plans. The mean percentage of the target volume receiving 98% of the prescription dose of 3D plans was 95.4% versus 98.9% among VMAT plans (P < .01). The mean target volume hotspot of 3D plans was 7200 cGy versus 5450 cGy for VMAT plans (P < .01). A mean ETV found for 3D plans was nearly double that found among VMAT plans (5.3% vs 2.7%, P < .01). VMAT plans resulted in lower doses to the shoulder and back. Mean total body volumes of VMAT plans were lower for dose thresholds of 100% to 130% of the prescription. VMAT plans generally had superior values for institutional normal tissue dose constraints. VMAT is superior to 3D planning across multiple metrics for breast cancer patients requiring CRNI. Insurance coverage for VMAT should not require 3D comparison plans.

Effect of Prepectoral Versus Subpectoral Implant-Based Reconstruction on Post-Mastectomy Radiation Dosimetry

BACKGROUND

The placement of breast implants in a prepectoral plane has become increasingly popular in breast reconstruction, although data on how this affects radiation delivery in women with breast cancer are limited. This study aimed to assess the dosimetric differences in radiation plans for immediate breast reconstruction between prepectoral and subpectoral implants.

METHODS

In this study, a retrospective review and dosimetric analysis of patients with breast cancer who underwent immediate implant-based reconstruction and postmastectomy radiation therapy (PMRT) were performed. Patients with pre- or subpectoral implants were matched 1:1 by use of boost and radiation field. Demographics and complications were compared using the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables. Dosimetric data were analyzed to compare doses to the target, heart, lungs, and pectoralis major using a Mann-Whitney U test.

RESULTS

The study identified 42 patients who met the inclusion criteria. Planning target volume (PTV) coverage was better in the prepectoral group (PTV D95%, 45.61 vs. 43.38 Gy; p = 0.04). The heart and lung doses did not differ. The patients with subpectoral implants had a lower absolute volume of pectoralis major receiving 20 to 45 Gy.

CONCLUSION

This assessment of radiation dosimetry for patients undergoing immediate breast reconstruction found that the primary dosimetric difference between prepectoral and subpectoral implants was the dose to the pectoralis major. Otherwise, no significant difference in target coverage was found. These data suggest that implant placement can be selected to optimize reconstructive outcomes, with less concern for compromise to the oncologic quality of PMRT.

Comparative Postoperative Complications of Acellular Dermal Matrix and Mesh Use in Prepectoral and Subpectoral One-Stage Direct to Implant Reconstruction: A Retrospective Cohort Study

BACKGROUND

One-stage direct-to-implant (DTI) breast reconstruction is increasingly popular with the use of prepectoral reconstruction leading to increased demand for structural scaffolds. It is vital to determine if differences in safety profiles exist among scaffolds.

METHODS

We performed a retrospective cohort study of consecutive patients in our breast cancer center undergoing DTI reconstruction. Outcomes relating to postoperative infections, wound complications, and implant related complications were extracted. Outcomes were grouped into major, minor, and long-term complications. Univariate and multivariate analysis determined outcome differences and accounted for confounding variables.

RESULTS

Two hundred forty-two patients (404 breasts) underwent DTI reconstruction. One hundred ninety-two breasts were reconstructed with FlexHD Pliable Preformed (PP; MTF Biologics, Edison, NJ), 122 with AlloDerm Ready To Use (RTU; Allergan Aesthetics, Irvine, CA), 22 with DermACELL (LifeNet Health, Virginia Beach, VA), 21 with Galaflex (Galatea Surgical, Lexington, MA), 22 with Meso BioMatrix (MTF Biologics), and 25 with autologous dermal flaps alone. Univariate analysis demonstrated statistically significant differences among scaffolds in the incidence of cellulitis treated with oral antibiotics, capsular contracture, explantation for capsular contracture, seroma requiring operative drainage, minor complications, and long-term complications. On multivariate regression, FlexHD PP had reduced rates of capsular contracture, explantation for capsular contracture, minor complications, and long-term complications compared to AlloDerm RTU. Reconstruction with Galaflex had increased rates of capsular contracture when compared to FlexHD PP.

CONCLUSIONS

Certain structural scaffolds have differing safety profiles that should be considered when selecting, which product to use in DTI reconstruction.

Impact of Immediate Unilateral Breast Reconstruction with Abdominal Flaps on Quality of Life: A Single-Center Prospective Interventional Study in Egypt

INTRODUCTION

Breast cancer is a significant global health challenge, particularly in Egypt, where mastectomy rates have risen due to increased awareness and advancements in breast imaging. This study investigated the impact of immediate breast reconstruction following mastectomy on quality of life (QoL) in Egyptian women during the COVID-19 pandemic. The research examined three abdominal flap techniques and their effect on patient QoL. Recognizing the scarcity of prior research in Egypt on advanced breast reconstruction and the limited implementation of multidisciplinary care models, this study aimed to address this gap in the literature.

PATIENTS AND METHODS

This single-center, prospective, non-randomized interventional study, conducted in Egypt between August 2020 and August 2022, involved 36 female patients who underwent breast reconstruction following mastectomy. Participants were classified into three groups (pedicled MS-TRAM flap, free DIEP flap, and delayed free DIEP flap) based on flap selection, guided by surgeon and patient counseling. While surgical techniques varied, preoperative assessments and postoperative care were standardized across all groups. QoL was assessed using the BREAST-Q assessment tool, with one assessment occurring 12 months after surgery.

RESULTS

This study showed that the three surgical groups demonstrated similar QoL outcomes, as assessed by the BREAST-Q. There were no significant differences in satisfaction with breast appearance, psychological well-being, sexual well-being, physical well-being of the abdomen, or physical well-being of the chest and upper body (p > 0.05 for all comparisons). Operative time was significantly longer for the free DIEP flap group compared to the MS-TRAM and delayed free DIEP groups (P = 0.001). Postoperative complications were infrequent and comparable across the groups, with no significant differences in total flap necrosis, partial flap loss, or fat necrosis (P =1.0 for all comparisons). The use of mesh support varied significantly among the groups, with 100% utilization in the MS-TRAM group compared to 34% in the free DIEP group and 16.7% in the delayed free DIEP group (P = 0.015 and P = 0.06, respectively).

CONCLUSION

In this Egyptian study, immediate unilateral ABR using different abdominal flap techniques resulted in similar QoL outcomes using BREAST-Q. This suggests that flap choice does not significantly impact patient well-being and satisfaction. Despite the limitations of this study, it emphasizes the importance of individualized surgical approaches based on patient needs and surgeon experience, particularly in resource-constrained settings. Further research is needed to validate these findings and explore long-term outcomes.

LEVEL OF EVIDENCE II

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 at www.springer.com/00266 .

Salvage of the Mastectomy Pocket in Infected Implant-Based Breast Reconstruction Using Negative-Pressure Wound Therapy with Instillation and Dwell: A Systematic Review and Meta-Analysis

Background: Breast cancer, irrespective of gender, stands as the most prevalent cancer globally, with an annual estimate of 2.3 million new cases. Surgical intervention, including therapeutic mastectomy (excluding prophylactic procedures), is performed on approximately 28% of patients, necessitating subsequent breast reconstruction. Although implant-based breast reconstruction (IBBR) is frequently employed due to its relative ease compared to autologous methods, it presents a notable risk for complications at mid-term such as peri-prosthetic infections. These complications can lead to implant loss and the eventual compromise of the mastectomy pocket. To address these complications, negative pressure wound therapy with instillation and dwell (NPWTi-d) emerges as a promising rescue intervention, known for its capacity to significantly reduce bacterial load and potentially salvage compromised soft tissues. However, the evidence supporting its effectiveness in infected pockets after mastectomy is currently insufficient. This study aims at investigating the efficacy of NPWTi-d in the management of peri-prosthetic mastectomy pocket infection. Methods: A thorough literature search has been concluded through PubMed, Web of Science, and Cochrane databases up until 18th March 2025 on evaluating NPWTi-d's ability to manage peri-prosthetic infections and preserve mastectomy pockets for subsequent reconstruction. Furthermore, a meta-analysis on the salvage rate of the mastectomy pocket was carried out, while for other outcomes, a descriptive analysis was applied. Results: Nine studies (n = 230 patients) were included, investigating whether the us NPWTi-d was successful in treating peri-prosthetic infection and preserving the mastectomy pocket for subsequent reconstruction by expander or implant. The pooled salvage rate of the implant-based BR due to the use of NPWTi-d was 86.1% (95%CI: 80.6-91.6%). Preservation of the skin envelope avoided secondary reconstruction after a defined time interval, reducing number and complexity of surgeries and related costs. Conclusions: This innovative surgical approach should be considered in selected cases of infected implants after breast reconstruction in breast cancer centers. However, the actual low level of evidence is based on case series, and it is not possible to define generally accepted recommendations for the use of NPWTi-d to save the mastectomy pocket.

High-Volume Fat Grafting With and Without Goldilocks Mastectomies Show Successful Clinical Outcomes for Breast Reconstruction

ABSTRACT

High-volume fat grafting is an autologous reconstructive technique that provides women with a minimally invasive surgical option, yet there remains a paucity of literature examining details about the reconstructive timeline and outcomes of this procedure. This study presents a retrospective review of a single surgeon's experience performing total autologous breast reconstruction using fat grafting alone or in combination with Goldilocks mastectomies. Our population included 39 breast reconstructions in 25 patients. Nineteen patients (28 breasts) had fat grafting only and 6 patients (11 breasts) had Goldilocks and fat grafting. On comparison, the fat grafting only group averaged 4 grafting sessions while the Goldilocks combined group averaged 2.64 sessions (P = 0.03). In the fat grafting only group, the total average volume of fat injected into each breast was 664 mL, and it was not significantly different from the Goldilocks combined group with 495 mL of fat (P = 0.111). In the fat grafting only group, there was a similar amount of fat injected in the first 5 grafting sessions; following the 5th session, there was a significant drop in volume grafted (P < 0.001). Four fat grafting-related complications were reported (10%) and 3 patients developed seromas following their Goldilocks mastectomies (27%). There were no tumor recurrences. We can conclude from this data that high-volume fat grafting is a successful and safe form of breast reconstruction. We show good volume achieved with minimal procedures necessary, especially when combined with Goldilocks mastectomies. This study depicts a reliable timeline for this autologous and safe reconstructive option.

Trends in Ancillary Procedures Following Staged Implant-Based Breast Reconstruction

BACKGROUND

The shift from submuscular to prepectoral breast reconstruction has contributed to anecdotal changes in practices around ancillary procedures, such as autologous fat grafting and nipple-areola complex (NAC) reconstruction. Although prepectoral reconstruction carries a lesser risk for muscular injury, postoperative pain and animation deformity, it is associated with decreased soft-tissue coverage and may necessitate ancillary procedures. This study examines operative trends following staged implant-based breast reconstruction to determine if tissue expander (TE) plane is associated with changes in the utilization of supplemental procedures.

METHODS

We conducted a retrospective review using the TriNetX research database of deidentified patient data. Using Current Procedural Terminology codes, we identified adult female patients who underwent (1) mastectomy, (2) TE placement between 2013 and 2020, and (3) implant exchange. We grouped patients by year of TE placement and collected postimplant procedure characteristics.

RESULTS

We identified 10,984 patients who underwent TE placement between 2013 and 2020 and subsequent implant exchange. There were 854 patients in the 2013 cohort and 1634 in the 2020 cohort. Fat grafting was 2.76-fold more prevalent in the 2020 cohort compared to the 2013 cohort (43.0% vs 15.6%, P < 0.001). Notably, the percentage of patients undergoing more than one round of fat grafting increased from 4.1% in the 2013 cohort to 11.9% in the 2020 cohort (P < 0.001). Fat grafting at the time of implant exchange was also more common in later cohorts, increasing from 6.6% of patients in the 2013 cohort to 32.0% in the 2020 cohort (P < 0.001). Over the study period, rates of NAC reconstruction were observed to decrease. A total of 10.3% of patients in the 2020 cohort underwent NAC reconstruction compared to 24.6% in the 2013 cohort (P < 0.001). Nipple tattooing procedures were also performed less frequently in recent cohorts.

CONCLUSIONS

In more recent cohorts, procedures aimed at correcting contour irregularities and rippling, specifically autologous fat grafting, have become more common. In contrast, the rates of NAC reconstruction and nipple tattooing have decreased, possibly because of challenges related to thin mastectomy skin flaps and limited soft-tissue coverage, which are more common in prepectoral reconstruction.

PDMS biointerfaces featuring honeycomb-like well microtextures designed for a pro-healing environment

Even today, the reduction of complications following breast implant surgery together with the enhancement of implant integration and performance through the modulation of the foreign body response (FBR), remains a fundamental challenge in the field of plastic surgery. Therefore, tailoring the material's physical characteristics to modulate FBR can represent an effective approach in implantology. While polydimethylsiloxane (PDMS) patterning on 2D substrates is a relatively established and available procedure, micropatterning multiscaled biointerfaces on a controlled large area has been more challenging. Therefore, in the present work, a specific designed honeycomb-like well biointerface was designed and obtained by replication in PDMS at large scale and its effectiveness towards creating a pro-healing environment was investigated. The grayscale masks assisted laser-based 3D texturing method was used for creating the required moulds in Polycarbonate for large area replication. By comparison to the smooth substrate, the honeycomb topography altered the fibroblasts' behaviour in terms of adhesion and morphology and reduced the macrophages' inflammatory response. Additionally, the microstructured surface effectively inhibited macrophage fusion, significantly limiting the colonization of both Gram-positive and Gram-negative microbial strains on the tested surfaces. Overall, this study introduces an innovative approach to mitigate the in vitro FBR to silicone, achieved through the creation of a honeycomb-inspired topography for prosthetic interfaces.

Clinical Outcomes Following Profunda Artery Perforator Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

There is a lack of reliable evidence on the surgical outcomes of profunda artery perforator (PAP) flap breast reconstruction. We conducted a meta-analysis to evaluate its safety and compare it with deep inferior epigastric perforator (DIEP) flap, aiming to offer more information on whether the PAP flap was an ideal alternative for autologous breast reconstruction.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The postoperative complication rates following PAP reconstruction were pooled. Mean differences of patients' age, BMI, mastectomy weight and flap weight between PAP and DIEP group were calculated, and relative risk was estimated to compare their incidence of complications.

RESULTS

Twenty-four articles reporting 1612 PAP flap breast reconstructions were included. The surgical success rate was 99.6%; the incidence of total and partial flap loss was 0.4% and 0.0%; the incidence of infection, hematoma, seroma, fat necrosis and wound dehiscence in recipient sites was 0.3%, 1.4%, 1.0%, 3.3% and 0.3%, respectively; the incidence of infection, hematoma, seroma, wound dehiscence and sensory disturbance in donor sites was 2.0%, 0.9%, 3.5%, 9.2% and 0.6%, respectively. Compared to the DIEP group, the average age, BMI, mastectomy weight and final flap weight were significantly lower in the PAP group. No significant difference was observed in terms of flap failure, breast fat necrosis and donor site wound dehiscence.

CONCLUSIONS

This systematic review demonstrates similar levels of postoperative morbidities for the PAP and DIEP flaps with some subtle differences and verifies the PAP flap as a second-line treatment for patients when the DIEP is unavailable or undesirable.

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 .

Simultaneous Symmetrizing Surgery on the Contralateral Breast in Unilateral Autologous Breast Reconstruction Is Cost-Effective

BACKGROUND

 Simultaneous symmetrizing surgery (SSS) at the time of unilateral free flap reconstruction has been described as a method to facilitate single-stage breast reconstruction. However, the impact on cost and number of additional procedures is not well described.

METHODS

 Patients with unilateral free flap reconstruction were identified in national administrative data from 2017 to 2021 and followed for one year. Patients were stratified by immediate and delayed reconstruction, then further stratified into groups with and without SSS. Thirty-day complications included transfusion, wound dehiscence, surgical site infection, hematoma/seroma, and thromboembolism. The costs of initial hospitalization and subsequent surgeries were determined. Deferred symmetrizing surgeries within one year were identified. Chi-squared and Fisher exact tests and Wilcoxon tests were used for statistical analysis.

RESULTS

 A total of 1,136 patients were identified, out of which 638 were delayed reconstructions: 75 with SSS and 563 without. There were no significant differences in patient characteristics or 30-day complications. Within one year of index reconstruction, fewer patients with SSS underwent revision surgery (29% vs. 51%, [p = 0.001]) or at least one additional procedure (36% vs. 57%, p < 0.001). Patients with SSS had lower total costs ($35,897 vs. $50,521, p = 0.005). There were 498 immediate reconstructions: 63 with SSS and 435 without. There were no significant differences in patient characteristics, 30-day complications, subsequent surgeries, or total costs.

CONCLUSION

 Symmetrizing procedures at the time of unilateral reconstruction may decrease the cost and number of subsequent surgeries without increasing complications.

Effects of Elective Revision after Breast Reconstruction on Patient-Reported Outcomes

BACKGROUND

 There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life.

METHODS

 A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015 to 2021. Patients were included if they had completed BREAST-Q preoperatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed.

RESULTS

 Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and body mass index (BMI) was 29.55 ± 5.63 kg/m2. Forty-eight patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or preoperative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared with after initial reconstruction alone (p = 0.04). Autologous reconstruction patients who had at least one revision had significantly higher satisfaction with outcome (p = 0.02) and satisfaction with surgeon (p = 0.05) in the 2-year follow-up period compared with patients who had no revisions.

CONCLUSION

 Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.

A Systematic Review of the Reporting Quality of Qualitative Research in Breast Plastic Surgery

Background:Qualitative research incorporates patients' voices into scientific literature. To date, there has been no formal review of qualitative research in plastic surgery. The primary objective of this study was to evaluate the reporting quality of "breast specific" plastic surgery qualitative research. Secondary objectives were to record study methodology and examine associations between reporting quality and publication/journal characteristics. Methods: MEDLINE, Embase, Psychinfo, and PubMed were searched to identify qualitative studies in breast plastic surgery. Findings were presented with descriptive analysis. Reporting quality was evaluated using the Standards for Reporting Qualitative Research (SRQR), a 21-item checklist. Results: Eighty studies were included. The median SRQR score was 17/21 (range: 6-21). The lowest reported SRQR items were qualitative approach (n = 29/80, 36%) and data collection method (n = 36/80, 45%). Nine (11%) studies described following a reporting guideline. Articles published in nursing journals had the highest average SRQR scores (18.4/21). There was no significant difference between studies published before or after the publication of SRQR (P = .06). Eighty-six percent of studies focused on patient experiences with breast reconstruction (n = 69/80). Conclusions: The introduction of the SRQR has not led to significant improvement in the reporting of qualitative research. Rationale for methodology was frequently missing. We recommend that investigators conducting qualitative research in breast plastic surgery ensure they provide a rationale for their methodology and become familiar with the SRQR reporting guideline.

Patient-reported outcomes 3 and 18 months after mastectomy and immediate prepectoral implant-based breast reconstruction in the UK Pre-BRA prospective multicentre cohort study

INTRODUCTION

Prepectoral techniques are becoming standard of care for implant-based breast reconstruction due to reduced impact on chest wall function and improved patient satisfaction. Evidence to support these benefits, however, is lacking. Here, patient-reported outcomes (PROs) of prepectoral breast reconstruction (PPBR) in the Pre-BRA cohort are reported.

METHODS

Women undergoing PPBR after mastectomy for breast cancer or risk reduction between July 2019 and December 2020 were recruited. Participants completed the BREAST-Q preoperatively and at 3 and 18 months following surgery together with a single item evaluating overall satisfaction at 18 months. Women completing at least one BREAST-Q scale at any timepoint were eligible for inclusion. Questionnaires were scored according to the developers' instructions and scores compared over time. Exploratory analysis, adjusting for baseline scores was performed to explore factors impacting PROs.

RESULTS

In total 338 of 343 (98.5%) women undergoing PPBR at 40 UK centres were included in the analysis. Compared with baseline scores, women reported statistically significant and clinically meaningful decreases in both 'Physical' and 'Sexual well-being' at 3 and 18 months. Adjusting for baseline, at 18 months, those experiencing implant loss or having surgery for malignancy reported lower scores in all BREAST-Q domains. Overall, two-thirds of women (167/251) rated the outcome of their reconstruction as 'excellent/very good', but experiencing major complications, implant loss, and being dissatisfied with wrinkling/rippling in the reconstructed breast were associated with reduced satisfaction.

CONCLUSIONS

PPBR impacts postoperative physical well-being and PROs are variable. These findings should be discussed with patients to support informed decision-making based on realistic expectations of outcome.

STUDY REGISTRATION

ISRCTN11898000.

Repeated Autologous Fat Grafting Significantly Increases Mastectomy Flap Thickness in Pre-Pectoral Multi-Stage Composite Expander-to-Implant Breast Reconstruction: Exploring the Concept of a Reverse Expansion

Background/Objectives: Combining autologous fat grafting with implant placement is meant to improve the quality of implant-based breast reconstruction. The present study explores the concept of multi-stage composite breast reconstruction with repeated sessions of autologous fat grafting to increase mastectomy flap thickness and provide better pre-pectoral implant coverage. Methods: Twenty-five consecutive patients underwent bilateral multi-stage composite expander-to-implant breast reconstruction and reverse expansion from August 2020 to April 2024. Subcutaneous thickness of the mastectomy flap was evaluated in predefined regions of interests of the breast on standardized MR images at two timepoints (before the first fat grafting session, with the tissue expander fully inflated, and 3 months after implant placement). Furthermore, the incidence of complications requiring surgery and implant-related complications were evaluated. All values are expressed as mean ± standard deviation, accepting statistical significance for a p-value < 0.05. Results: Patients underwent an average of 2.5 ± 0.6 fat grafting sessions, with a fat injection volume of 170 ± 60 mL per breast per session. The mean duration of the reconstructive process from mastectomy to final implant placement was 12 ± 5 months and the mean follow-up was 17 ± 8 months. The overall thickness of both breasts amounted to 190% of baseline thickness and was significantly higher in the upper breast quadrants than in the lower quadrants (p < 0.05). Tissue thickness increase correlated well with the number of fat grafting sessions and was independent of the patient's weight gain. Complications requiring surgery occurred in eight breasts during the reconstruction, with iatrogenic expander puncture being the most frequent (three cases, 6%). During follow-up, only one implant-related complication was observed (one case of bilateral rippling, 4%). No breast animation or symptomatic capsular contracture were observed. Conclusions: Multi-stage pre-pectoral composite expander-to-implant breast reconstruction using autologous fat grafting is an effective concept for breast reconstruction. Despite the need for multiple surgeries, the significant increase in subcutaneous tissue thickness, resulting in better soft tissue coverage, compensates for the longer reconstructive process.

Comparison of outcomes following prepectoral and subpectoral implants for breast reconstruction in patients with breast cancer

Background

In recent years, different approaches to implant-based breast reconstruction have increasingly become an important option to meet both the treatment and postoperative aesthetic needs of breast cancer patients. This study selected two commonly used techniques for the prepectoral approach: single-incision, gas-inflated endoscopic prepectoral breast reconstruction (SIE-BR) and open prepectoral implant-based breast reconstruction (C-BR), as well as a commonly used technique for the subpectoral approach: open subpectoral implant-based breast reconstruction (SI-BR). By comparing the clinical efficacy and aesthetic outcomes of these three techniques in the treatment of breast cancer patients, this study aims to summarize the advantages of the prepectoral approach.

Methods

This study screened the clinicopathological data of a total of 136 breast cancer patients from January 2023 to December 2023. Among them, 38 patients underwent SIE-BR, 51 patients underwent C-BR, and 47 patients underwent SI-BR. The patient characteristics, intraoperative and postoperative conditions were analyzed in detail, and satisfaction was assessed using the BREAST-Q questionnaire.

Results

The SIE-BR group had the longest surgery time, followed by the SI-BR group, with the C-BR group having the shortest surgery time. The C-BR group had the least blood loss, while the SIE-BR group had the most. The C-BR group also had the lowest drainage volume, and the SIE-BR group had the highest. Patients were categorized into a prepectoral implant-based reconstruction group (PIBR) and a subpectoral implant-based reconstruction group (SIBR). None of the patients experienced implant loss or flap necrosis. The PIBR group had significantly lower rates of wound infection, capsular contracture, and chest muscle pain compared to the SIBR group. The rates of wound dehiscence and implant wrinkling were statistically similar between the two groups. BREAST-Q scores indicated similar satisfaction in terms of breast appearance and sexual life between the groups, but the PIBR group showed significantly better scores in physical health (chest muscle function preservation) and mental health. Additional advantages of the prepectoral approach, including less postoperative pain, reduced movement-related deformity, and shorter surgery time, have contributed to the steady growth of this technique in recent years.

Conclusion

The three implant-based breast reconstruction techniques mentioned above are safe and feasible. Compared to the previously more common subpectoral approach, the prepectoral approach improves patients' postoperative physical and psychological comfort, making it an ideal surgical option.

Beyond Surgery: Psychological Well-Being's Role in Breast Reconstruction Outcomes

INTRODUCTION

Breast cancer is one of the most prevalent cancers worldwide, and following its treatment, many women turn to plastic surgery for reconstruction. A diagnosis of cancer is a heavy burden on patients. Yet, the effect of psychological/psychiatric comorbidities on patient satisfaction following their reconstruction remains unexplored. Thus, this paper aims to investigate how pre-existing psychological and psychiatric conditions impact patient-reported outcomes postreconstruction, compared to women without such conditions.

METHODS

A systematic review of PubMed, Web of Science, and Cochrane was completed. A qualitative synthesis of all included studies was then performed, and a subgroup analysis was then performed using a random effect model.

RESULTS

A total of 24 papers were included, encompassing a total population of 220,565 patients undergoing breast reconstruction between the ages of 18 and 84. The follow-up time ranged between 1.5 mo and 61 mo. In our study of breast reconstruction outcomes, the cohort with psychological/psychiatric comorbidities exhibited significant decreases in postoperative BREAST-Q scores compared to the control group: a 24-point [95% confidence interval (CI; -40, -8)] difference in satisfaction, a 20-point [95% CI (-57, -17)] difference in psychosocial well-being, an 18-point [95% CI (-28, 9)] difference in physical well-being, and a 33-point [95% CI (-51, -15)] difference in sexual well-being.

CONCLUSIONS

Ultimately, our analysis suggests that presurgical psychology status is a critical determinant of postsurgical patient-reported outcomes. These results encourage the development and inclusion of well-being screening and optimization prior to surgery as a mean to improve surgical outcomes.

Microsurgeon Development, Attrition, and Hope for the Future: A Qualitative Analysis

BACKGROUND

 The field of microsurgery continues to grow, yet barriers to practice still exist. This qualitative study aims to elucidate factors both strengthening and threatening this subspecialty through structured interviews with fellowship-trained microsurgeons.

METHODS

 An interview guide was designed, and structured interviews were conducted with practicing fellowship-trained microsurgeon members of the American Society of Reconstructive Microsurgeons between August 2021 and May 2022. Three independent reviewers transcribed, content-coded, and thematically analyzed the interviews. Themes and subthemes were discussed and finalized.

RESULTS

 Twenty-one practicing microsurgeons were interviewed, hailing from all four Census geographical regions of the United States. The most common practice model was academic (43%, n = 9). Five overarching themes emerged: a passion for microsurgery, training and mentorship, practical considerations, team support, and hope for the future. Microsurgeons reported early exposure to microsurgery as catalyzing their passion, whereas a strong training foundation and lifelong mentors sustained it. Practical challenges arose when establishing and maintaining a microsurgery practice, such as poor reimbursement and unfavorable referral patterns. Team support from staff and other microsurgeons (e.g., a co-surgeon model) was crucial to success. Finally, microsurgeons hoped that future advances would expand access to microsurgical reconstruction for patients and plastic surgeons.

CONCLUSION

 This unique, qualitative description of the current landscape of microsurgery revealed that though practical barriers exist, team-based models can alleviate some difficulties. Future advances that increase accessibility may further strengthen this unique and versatile field.

Complications and patient-reported outcomes after radiotherapy in breast cancer patients undergoing implant-based breast reconstruction: a retrospective study from a large Chinese breast disease center

BACKGROUND

Postmastectomy radiation therapy (PMRT) can influence the outcome of implant-based breast reconstruction (IBBR). This study aims to investigate the complications and patient-reported outcomes (PROs) following PMRT between direct-to-implant (DTI) and tissue expander-to-implant (TEI) reconstruction.

METHODS

The retrospective study included breast cancer patients undergoing IBBR and PMRT. Patients were divided into a permanent implant group (PI-PMRT) and a tissue expander group (TE-PMRT). Complications, reconstruction failure, and reoperation were compared between the two groups. PROs were assessed using the BREAST-Q scale.

RESULTS

A total of 203 patients were included: 99 in the PI-PMRT group and 104 in the TE-PMRT group. The incidence of severe capsular contracture was significantly higher in the PI-PMRT group compared to the TE-PMRT group (37.4% vs. 24.0%, p = 0.039). The PI-PMRT group had a significantly lower rate of reconstruction failure (9.1% vs. 19.2%, p = 0.039) and reoperation (13.1% vs. 24.0%, p = 0.046). Multivariate analysis revealed that the absence of mesh (OR = 2.177, p = 0.040) and DTI reconstruction (OR = 1.922, p = 0.046) were independent predictors of severe capsular contracture; the absence of mesh (OR = 4.699, p = 0.015) and TEI reconstruction (OR = 2.429, p = 0.043) were independent predictors of reconstruction failure. BREAST-Q scores indicated greater breast satisfaction in the PI-PMRT group (p = 0.031).

CONCLUSIONS

Although DTI reconstruction resulted in a higher risk of severe capsular contracture, the higher risk of reconstruction failure and reoperation in patients undergoing TEI reconstruction was even more concerning. Furthermore, patients were more likely to report greater breast satisfaction with DTI reconstruction. Therefore, DTI reconstruction may be a more appropriate option for patients anticipating PMRT.

Autologous Fat Breast Reconstruction with Implant Completion-Experience with 29 Consecutive Cases and 33 Breasts

BACKGROUND

Implant-based breast reconstruction is the most prevalent form of breast reconstruction. Autologous fat grafting (AFG) was conceptualized as an alternative to implant-based breast reconstruction and was found to be a reliable reconstruction modality. However, usually, a few grafting rounds are required to create the desired shape and size of the breast. Current literature describes ample experience with AFG as an adjunct to implant-based breast reconstruction for improving appearance. However, the utilization of breast implants following initial AFG has been sparingly described. The primary advantage of this study is the creation of new fat tissue as a breast mound. The reconstruction is then concluded by inserting an implant into this new mound. This approach reduces the overall number of fat injections needed to achieve the desired outcome, as well as the total volume of the implant.

METHODS

This IRB-approved retrospective study was conducted between January 2015 and December 2021. All women who underwent delayed breast reconstruction with AFG during this timeframe and wanted to complete it with a silicone implant as a last stage were included in the study.

RESULTS

A total of 29 patients (33 breasts) underwent delayed breast reconstruction with AFG and a silicone implant as the final stage. In all cases, the results were satisfying without any major complications. Minor complications were observed with one patient and included an infection.

CONCLUSIONS

The findings of this study have demonstrated the effectiveness of this procedure together with patient satisfaction, thus highlighting the potential advantages that this approach offers.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Immediate Unilateral Subpectoral Implant-Based Breast Reconstruction does not Impair Pulmonary Functions: A Preliminary Prospective Study

BACKGROUND

Implant-based breast reconstruction is one of the most common procedures among women with breast cancer undergoing mastectomy. Prosthetic devices may be positioned either beneath or above the pectoralis major muscle, which is considered an accessory muscle of ventilation. This preliminary prospective study aimed to investigate whether subpectoral unilateral implant-based breast reconstruction has any effect on patients' pulmonary functions.

METHODS

A prospective study of fourteen women who underwent immediate unilateral implant-based subpectoral breast reconstruction by a single surgeon over 10 months was conducted. Spirometry and maximal voluntary ventilation tests were conducted 1 day prior to surgery, and 1- and 3 months following breast reconstruction. ANOVA or Friedman test were used to compare pulmonary function tests before and after surgery.

RESULTS

Fourteen patients completed the study protocol. No statistically significant differences were found when comparing spirometry parameters in the three time points.

CONCLUSIONS

Pectoralis muscle release does not impair pulmonary function among patients undergoing immediate unilateral implant-based breast reconstruction following mastectomy.

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 .

Understanding healing complications in implant-based breast reconstruction using novel metrics for indocyanine green angiography

INTRODUCTION

Indocyanine green (ICG) angiography for the intraoperative evaluation of tissue perfusion is commonly used in implant-based breast reconstruction (IBR). The assessment of ICG images depends on the surgeon's interpretation and is qualitative or semiqualitative in nature. To quantify ICG metrics, this study aimed to apply a novel assessment of fill-rate dynamics to predict wound-healing complications and provide pragmatic assessment tools in IBR.

METHODS

This was a retrospective cohort study of patients who underwent IBR with ICG using the photodynamic eye (PDE-Neo II) qualitative imaging system between April 2021 and September 2023. ICG recordings were reviewed to quantify the relative surface area and fluorescence intensity of visual perfusion deficits using ImageJ. The primary outcome was the incidence of wound-healing complications. t-tests and logistic regression were performed for statistical testing.

RESULTS

A total of 112 patients (201 breasts) were included. The incidence of wound-healing complications was 12.9%. A higher relative surface area of ischemic regions was significantly associated with wound-healing complications (3.3% vs. 0.90%; p = 0.001). The rate of change in the surface area of ischemic regions was significantly associated with wound-healing complications (0.35% per second vs. 1.29% per second; p = 0.003%). On average, the duration of transient ischemic areas was significantly longer in breasts with wound-healing complications (46.0 s vs. 36.0 s, p = 0.01).

CONCLUSION

A transient ischemic area of > 5% of the breast and/or failure to resolve transient ischemic areas after 60 s may predict wound-healing complications and inform surgical reconstructive decision-making in IBR.

Acellular Dermal Matrix without Basement Membrane in Immediate Prepectoral Breast Reconstruction: A Randomized Controlled Trial

BACKGROUND

Acellular dermal matrix (ADM) has become popular in various reconstructive procedures of different anatomic regions. There are different needs depending on the clinical application, including breast, abdominal wall, and any other soft-tissue reconstruction. Removal of the basement membrane, which consists of collagen fibers, may help achieve natural and soft breast reconstruction, which requires highly elastic ADMs. Given the lack of knowledge of the effectiveness of ADM without the basement membrane, the authors compared the clinical outcomes of ADMs with and without basement membrane in breast reconstruction.

METHODS

The authors conducted a single-blind randomized controlled trial to evaluate differences in clinical outcomes. The patients were randomized into 2 groups: ADM with or without basement membrane. Both groups underwent immediate prepectoral direct-to-implant breast reconstruction. Demographic characteristics, surgical outcomes, and breast shape change using nipple position were compared between the 2 groups.

RESULTS

A total of 56 patients were divided into 2 groups: ADM with basement membrane (n = 30 [53.6%]) or ADM without basement membrane (n = 26 [46.4%]). Clinical and surgical characteristics were similar between the 2 groups. The authors detected no statistically significant differences in the overall rate of complications or breast shape change between the 2 groups. However, the rate of seromas was higher in the ADM with basement membrane group than in the ADM without basement membrane group (10% versus 0%; P = 0.09).

CONCLUSIONS

The 2 groups showed similar surgical outcomes. ADM without basement membrane in implant-based breast reconstruction was safe, and had mechanical properties of lower tensile strength and higher elasticity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The Role of Density in Achieving Volume and Weight Symmetry in Breast Reconstruction

BACKGROUND

 Knowledge of tissue and implant density is crucial in obtaining both volume and weight symmetry in unilateral breast reconstruction. Therefore, the aim of this study was to determine and compare the density of abdominal and breast tissue specimens as well as of 5th generation breast implants.

METHODS

 Thirty-one breast tissue and 30 abdominal tissue specimens from 61 patients undergoing either mammaplasty or abdominoplasty as well as five different 5th generation breast implants were examined. Density (g/mL) was calculated by applying the water displacement method.

RESULTS

 The mean specimen density was 0.94 ± 0.02 g/mL for breast tissue and 0.94 ± 0.02 g/mL for abdominal tissue, showing no significant difference (p = 0.230). Breast tissue density significantly (p = 0.04) decreased with age, while abdominal tissue did not. A regression equation to calculate the density of breast tissue corrected for age (breast density [g/mL] = 0.975-0.0007 * age) is provided. Breast tissue density was not related to body mass index, past pregnancy, or a history of breastfeeding. The breast implants had a density ranging from 0.76 to 1.03 g/mL which differed significantly from breast tissue density (-0.19 g/mL [-19.8%] to +0.09 g/mL [+9.58%]; p ≤ 0.001).

CONCLUSION

 Our results support the suitability of abdominal-based perforator flaps in achieving both volume and weight symmetry in unilateral autologous breast reconstruction. Abdominal flap volume can be derived one-to-one from mastectomy weight. Further, given significant brand-dependent density differences, the potential to impose weight disbalances when performing unilateral implant-based reconstructions of large breasts should be considered.

Quality of life in breast reconstruction: a comparison of lightweight and conventional breast implants

BACKGROUND

Due to the declining mortality rates of breast carcinoma and the rising incidence of risk-reducing mastectomies, enhancing the quality of life after breast reconstructions has become an increasingly important goal. The advantages of lightweight breast implants (B-Lite®) may significantly contribute to achieving this objective. This study aims to investigate whether lightweight implants are suitable for patients undergoing breast reconstruction and could improve the quality of life in comparison to conventional implants.

METHODS

In this study, we retrospectively analyzed 48 patients (38 implants in each group) who underwent implant-based breast reconstruction with either B-Lite® or conventional breast implants between 2019 and 2022 at the University Center for Plastic Surgery in Regensburg. As part of the postoperative follow-up, a clinical examination and a survey using the Breast-Q® questionnaire were conducted to evaluate the postoperative quality of life.

RESULTS

The implants used were similar in weight and shape. On average, the B-Lite® implants had a higher implant volume and patients in this group had a slightly higher BMI. Patients who received B-Lite® implants showed a significantly better result regarding the sensation of sensitivity in the surgical area and the scar formation also appeared to be more favorable. However, patients with B-Lite® implants perceived their implants as more uncomfortable than those with conventional breast implants. In other terms concerning quality of life, both groups appeared similar.

CONCLUSION

In summary, there are confounding factors that could influence the outcome of some aspects in this study, which could not be avoided due to the retrospective study design and the temporary suspension of B-Lite implants. Nevertheless, as the first of its kind, this study demonstrated that B-Lite implants could also be suitable for usage in breast reconstructions, thus providing an important foundation for further prospective studies to build upon.

Predicting Postoperative Satisfaction with Breasts: How Important is the Preoperative BREAST-Q Score?

BACKGROUND

The role that preoperative Satisfaction with Breast plays in a patient's postoperative course after postmastectomy breast reconstruction (PMBR) is not understood. The aim of this study is to understand the impact of the preoperative score on postoperative outcome as an independent variable.

METHODS

We examined patients who underwent PMBR between 2017 and 2021 and who completed the BREAST-Q Satisfaction with Breasts at 1 year postoperatively. Two multiple linear regression models (Model 1 with the preoperative Satisfaction with Breasts score and Model 2 without the preoperative score), likelihood ratio tests, simple t-statistics, and sample patient dataset to predict the 1 year score were performed. Multiple imputation was used to account for missing preoperative scores.

RESULTS

Overall, 2324 patients were included. Model 1 showed that the preoperative score is significantly associated with the postoperative score (β = 0.09, 95% confidence interval 0.04-0.14; p < 0.001). Comparing Model 1 and Model 2 demonstrated that including preoperative Satisfaction with Breasts in a regression significantly improves model fit (test statistic = 10.04; p = 0.0021). Using the absolute value of the t-statistics as a measure of variable importance in linear regression, the importance of the preoperative score was quantified as 3.39-more important than neoadjuvant radiation, mastectomy weight, body mass index, bilateral prophylactic mastectomy, and race, but less than adjuvant radiation, reconstruction type, and psychiatric diagnoses.

CONCLUSION

Preoperative Satisfaction with Breasts scores are an important independent predictor of postoperative satisfaction after PMBR. Just as vital sign and work-up are carefully documented before surgery, preoperative scores should be collected to pre-emptively gauge patients' satisfaction and optimize postoperative outcomes.

Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis

BACKGROUND

 Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS).

METHODS

 A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes.

RESULTS

 Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different.

CONCLUSION

 CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Hypofractionated vs Conventionally Fractionated Postmastectomy Radiation After Implant-Based Reconstruction: A Randomized Clinical Trial

Importance

Postmastectomy radiation therapy (PMRT) improves local-regional disease control and patient survival. Hypofractionation (HF) regimens have comparable efficacy and complication rates with improved quality of life compared with conventional fractionation (CF) schedules. However, the use of HF after mastectomy in patients undergoing breast reconstruction has not been prospectively examined.

Objective

To compare HF and CF PMRT outcomes after implant-based reconstruction.

Design, Setting, and Participants

This randomized clinical trial assessed patients 18 years or older undergoing mastectomy and immediate expander or implant reconstruction for breast cancer (Tis, TX, or T1-3) and unilateral PMRT from March 8, 2018, to November 3, 2021 (median [range] follow-up, 40.4 [15.4-63.0] months), at 16 US cancer centers or hospitals. Analyses were conducted between September and December 2023.

Interventions

Patients were randomized 1:1 to HF or CF PMRT. Chest wall doses were 4256 cGy for 16 fractions for HF and 5000 cGy for 25 fractions for CF. Chest wall toxic effects were defined as a grade 3 or higher adverse event.

Main Outcomes and Measures

The primary outcome was the change in physical well-being (PWB) domain of the Functional Assessment of Cancer Therapy-Breast (FACT-B) quality-of-life assessment tool at 6 months after starting PMRT, controlling for age. Secondary outcomes included toxic effects and cancer recurrence.

Results

Of 400 women (201 in the CF arm and 199 in the HF arm; median [range] age, 47 [23-79] years), 330 patients had PWB scores at baseline and at 6 months. There was no difference in the change in PWB between the study arms (estimate, 0.13; 95% CI, -0.86 to 1.11; P = .80), but there was a significant interaction between age group and study arm (P = .03 for interaction). Patients younger than 45 years had higher 6-month absolute PWB scores if treated with HF rather than CF regimens (23.6 [95% CI, 22.7-24.6] vs 22.0 [95% CI, 20.7-23.3]; P = .047) and reported being less bothered by adverse effects (mean [SD], 3.0 [0.9] in the HF arm and 2.6 [1.2] in the CF arm; P = .02) or nausea (mean [SD], 3.8 [0.4] in the HF arm and 3.6 [0.8] in the CF arm; P = .04). In the as-treated cohort, there were 23 distant (11 in the HF arm and 12 in the CF arm) and 2 local-regional (1 in the HF arm and 1 in the CF arm) recurrences. Chest wall toxic effects occurred in 39 patients (20 in the HF arm and 19 in the CF arm) at a median (IQR) of 7.2 (1.8-12.9) months. Fractionation was not associated with chest wall toxic effects on multivariate analysis (HF arm: hazard ratio, 1.02; 95% CI, 0.52-2.00; P = .95). Fewer patients undergoing HF vs CF regimens had a treatment break (5 [2.7%] vs 15 [7.7%]; P = .03) or required unpaid time off from work (17 [8.5%] vs 34 [16.9%]; P = .02).

Conclusions and Relevance

In this randomized clinical trial, the HF regimen did not significantly improve change in PWB compared with the CF regimen. These data add to the increasing experience with HF PMRT in patients with implant-based reconstruction.

Trial Registration

ClinicalTrials.gov Identifier: NCT03422003.

Breast cancer-related lymphedema: A critical review on recent progress

Lymphedema is a chronic and debilitating condition characterized by an abnormal buildup of protein-rich fluid in the interstitial tissue, leading to the development of edema and tissue structural alterations. Breast cancer-related lymphedema (BCRL) remains a significant healthcare burden because it can develop within days and up to 11-years after the surgery. Specifically, axillary lymph node dissection leads to 30-50 % upper limb lymphedema, which involves the accumulation of protein-rich fluid. In this article, we provide a comprehensive/critical overview of post-mastectomy lymphedema, focusing on key aspects as diagnosis, prevention, and treatment methods. Beginning with clinical condition, the article explores the pathophysiology and risk factors associated with post-mastectomy lymphedema. It further delves into various diagnostic modalities available, highlighting the importance of early detection for optimal management of BCRL. We also examine preventive strategies, emphasizing the role of patient education, lifestyle modifications, and proactive measures in reducing the risk of lymphedema development. In terms of treatment, the article covers a wide array of interventions ranging from conservative approaches like manual lymphatic drainage and compression therapy to surgical techniques such as lymph node transfer and lymphaticovenular anastomosis. Thus, through a comprehensive synthesis of current evidence and clinical practices updates, the review aims to guide healthcare professionals in delivering preventive and effective care while improving outcomes for individuals affected by post-mastectomy lymphedema.

National Trends and In-Hospital Outcomes for Immediate Implant-Based Versus Autologous-Based Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Breast reconstruction consists primarily of two methods: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). Each of these methods has its advantages and disadvantages. The current study used the National Inpatient Sample (NIS), the largest inpatient database in the United States, to explore the trends, complications, and disparities in the use of IBR and ABR.

METHODS

The current study used the NIS database from 2016 to 2020, including the International Classification of Diseases, 10th version (ICD-10) codes. A propensity score-matching (1:1) analysis was used to match the IBR and ABR groups.

RESULTS

The percentage of breast reconstruction increased from 58.8% in 2016 to 63.4% by 2020. The trend of ABR was upward, and the trend of IBR was downward. In addition, the ABR group had significantly higher rates of cardiovascular complications (odds ratio [OR], 1.29), respiratory complications (OR, 4.26), vascular complications requiring surgery (OR, 7.82), blood transfusions (OR, 3.44), vasopressor need (OR, 1.409), and acute kidney injury (OR, 1.68). However, the ABR group had significantly lower rates of wound infection (OR, 0.430), wound dehiscence (OR, 0.213), wound seroma (OR, 0.602), and sepsis (OR, 0.252). A significant disparity was found in using ABR for different subgroups based on age, hospital teaching status, racial background, socioeconomic status, and hospital bed size.

CONCLUSION

The current study showed an upward trend in the utilization of ABR and a downward trend for IBR. Although ABR had a higher rate of pulmonary, cardiovascular, vascular, and bleeding complications, it had a lower rate of wound-related complications.

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020

BACKGROUND

 With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing.

METHODS

 We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service count numbers, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual percentage changes for the included CPT codes.

RESULTS

 Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%) but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%).

CONCLUSIONS

 Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for PMBR procedures may be considered by policymakers.

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

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

A Systematic Review of Questionnaires Assessing Patient Satisfaction in Plastic Surgery: Tools, Topics, and Surgical Types

Background

Patient satisfaction is crucial for evaluating healthcare services, including plastic surgery. This systematic review aims to analyze questionnaires assessing patient satisfaction in plastic surgery, identifying their strengths and weaknesses to improve outcomes and enhance the quality of care.

Methods

A comprehensive literature search was conducted using electronic databases. Studies were included if they were original research articles, written in English, and focused on patient satisfaction questionnaires in plastic surgery. Data extraction and descriptive statistics were used to summarize the data.

Results

A total of 105 studies were included. General/overall satisfaction was the most common topic addressed (99.04%). Cosmetic outcomes were the most frequently assessed category (34.3%). Breast reconstruction was the most common procedure (33.3%). Most studies used a combination of generic and procedure-specific questionnaires (45.71%). The most frequently used measurement tools were BREAST-Q and self-developed questionnaires, each accounting for 28.57% and 27.61%.

Conclusions

This review provides a comprehensive analysis of patient satisfaction questionnaires in plastic surgery, emphasizing the importance of a holistic approach and well-established, validated tools. The findings contribute to improving plastic surgery outcomes and enhancing the quality of care. Future research should refine assessment tools to address patients' needs and promote patient-centered outcomes in plastic surgery.

Complications of Aesthetic and Reconstructive Breast Implant Capsulectomy: An Analysis of 7486 Patients Using Nationwide Outcomes Data

BACKGROUND

Despite increasing demand for breast capsular surgery to treat various benign and malignant implant-related pathologies, high-quality evidence elucidating complication profiles of capsulectomy and capsulotomy is lacking.

OBJECTIVES

The aim of this study was to provide the largest-scale analysis of associated outcomes and complications using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, and to investigate clinical scenarios that may subject patients to increased risks for complications, most notably extent of capsular surgery (complete vs partial) and index indication of implantation (aesthetic vs reconstructive).

METHODS

An analysis of the TOPS database from 2008 to 2019 was performed. CPT codes were used to identify complete capsulectomy and partial capsulectomy/capsulotomy cases. Breast implant exchange procedures constituted procedural controls.

RESULTS

In total, 7486 patients (10,703 breasts) undergoing capsulectomy or capsulotomy were assessed. Relative to controls, capsulectomy (4.40% vs 5.79%), but not capsulotomy (4.40% vs 4.50%), demonstrated higher overall complication rates. Both capsulectomies (0.83% vs 0.23%) and capsulotomies (0.56% vs 0.23%) also had greater rates of seroma relative to controls. Subgroup analyses demonstrated that reconstructive patients, relative to aesthetic patients, experienced greater overall complications (6.76% vs 4.34%), and increased risks for seroma (1.06% vs 0.47%), dehiscence (0.46% vs 0.14%), surgical site infections (1.03% vs 0.23%), and implant loss (0.52% vs 0.23%). A detailed synthesis of 30-day outcomes, including all patient- and breast-specific complications, for both capsulectomy and capsulotomy, stratified according to all potential confounders, is presented herein.

CONCLUSIONS

Surgeries on the breast capsule are safe overall, although complete capsulectomies and reconstructive patients are associated with significantly increased operative risks. The present findings will enhance patient selection, counseling, and informed consent.

LEVEL OF EVIDENCE: 3

Trends and Early Complications in Direct-to-Implant Breast Reconstruction: An Updated Analysis of the ACS-NSQIP Database

Background: Rates of direct-to-implant (DTI) breast reconstruction, in which breast implants are placed at the time of mastectomy, have been consistently rising. Advances in surgical adjuncts and technology, such as acellular dermal matrices (ADM), have made DTI reconstruction safer and more reliable. However, few studies have characterized early (30-day) postoperative complications following DTI. The aim of this study was to obtain a current understanding of early postoperative outcomes following DTI breast reconstruction. Methods: Using data from the American College of Surgeons-National Surgical Quality Improvement Program, we analyzed complications for female patients who underwent DTI reconstruction from 2017 to 2019, as well as trends in DTI reconstruction from data on mastectomy and DTI reconstruction from 2010 to 2019. We grouped complications into major surgical (including return to the operating room) or medical complications. Statistical analysis was performed using Fischer's exact test for categorical variables, Student's t-test for continuous variables, and logistic regression. Results: DTI breast reconstruction rates have increased since 2010. Among our 2017-2019 cohort of 4204 patients, the early major surgical complication rate was approximately 10% (422 patients) and the major medical complication rate was 0.83% (35 patients). Regression modeling identified body mass index, smoking status, hypertension, bleeding disorders, and intraoperative blood transfusion as having a relationship with surgical complications (P < .001). Conclusions: Despite increased use of ADM and indocyanine green angiography, compared to prior studies, early postoperative complications have remained stable. Further studies are needed to assess long-term complications and patient-reported outcomes in DTI breast reconstruction.

Air Versus Saline in Tissue Expanders: A Systematic Review of the Literature

BACKGROUND

 There has been a greater focus in recent literature proposing air to be a superior medium to saline in tissue expanders. This study aims to review the literature and assess the quality of data on the efficacy and safety of air as an alternative medium to saline in tissue expanders, in the setting of postmastectomy two-stage reconstruction.

METHODS

 A systematic review regarding air inflation of tissue expanders was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three reviewers separately performed data extraction and comprehensive synthesis.

RESULTS

 A total of 427 articles were identified in our search query, of which 11 met the inclusion criteria. Three pertained to inflation with room air, and eight pertained to inflation with CO2 using the AeroForm device. They were comparable to decreased overall complication rates in the room air/CO2 cohort compared to saline, although statistical significance was only observed in one of five two-arm studies. Investigating specific complications in the five two-arm studies, significantly lower rates of skin flap necrosis were only observed in two CO2-based studies. Studies rarely discussed other safety profile concerns, such as the impacts of air travel, radiation planning, and air extravasation beyond descriptions of select patients within the cohort.

CONCLUSION

 There is insufficient evidence to suggest improved outcomes with room air inflation of tissue expanders. Further work is needed to fully characterize the benefits and safety profiles of air insufflation before being adopted into clinical practice.

Disparities in Postmastectomy Reconstruction Use among American Indian and Alaska Native Women

BACKGROUND

American Indian/Alaska Native (AI/AN) breast cancer patients undergo postmastectomy reconstruction (PMR) infrequently relative to non-Hispanic White (NHW) patients. Factors associated with low PMR rates among AI/AN women are poorly understood. The authors sought to describe factors associated with this disparity in surgical care.

METHODS

A retrospective cohort study of the National Cancer Database (2004 to 2017) identified AI/AN and NHW women, aged 18 to 64, who underwent mastectomy for stage 0 to III breast cancer. Patient characteristics, annual PMR rates, and factors associated with PMR were described with univariable analysis, the Cochran-Armitage test, and multivariable logistical regression.

RESULTS

A total of 414,036 NHW and 1980 AI/AN women met inclusion criteria. Relative to NHW women, AI/AN women had more comorbidities (20% versus 12%; Charlson Comorbidity Index ≥ 1; P < 0.001), had nonprivate insurance (49% versus 20%; P < 0.001), and underwent unilateral mastectomy more frequently (69% versus 61%; P < 0.001). PMR rates increased over the study period, from 13% to 47% for AI/AN women and from 29% to 62% for NHW women ( P < 0.001). AI/AN race was independently associated with decreased likelihood of PMR (OR, 0.62; 95% CI, 0.56 to 0.69). Among AI/AN women, decreased likelihood of PMR was significantly associated with older age at diagnosis, more remote year of diagnosis, advanced disease (tumor size >5 cm, positive lymph nodes), unilateral mastectomy, nonprivate insurance, and lower educational attainment in patient's area of residence.

CONCLUSIONS

PMR rates among AI/AN women with stage 0 to III breast cancer have increased, yet they remain significantly lower than rates among NHW women. Further research should elicit AI/AN perspectives on PMR, and guide early breast cancer detection and treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Public Preferences for Surgeon Gender in Saudi Arabia: A Cross-Sectional Analysis

BACKGROUND

Gender equity in healthcare ensures equal access to services and resources for all individuals, regardless of gender. Studies show that patients' gender influences their healthcare experiences and decisions, and societal gender preferences impact surgeon selection. Therefore, the objective of this study was to address the surgeons' gender preferences among Saudi Arabia's population.

METHODS

This study used a cross-sectional research design and survey methodology to gather data from a representative sample of adults aged 18 and older from the general population in Saudi Arabia. This study used SPSS version 26 for statistical data entry and analysis, employing descriptive and inferential statistics, frequency distributions, descriptive statistics, and multivariate analysis using multiple logistic regression for variables significantly associated with population gender in univariate analysis.

RESULTS

This study involved 2085 participants, with 51.2% aged 18-25, 18.4% aged 26-35, 16.7% aged 36-45, and 13.8% aged 45 and above. The majority were Saudi Arabian, with a majority holding a university degree. The majority worked in the healthcare sector, while the remaining 29.7% were unemployed. This study found that there were significant gender preferences among survey respondents for different types of surgical procedures. Male participants preferred male surgeons for routine non-emergency visits and sensitive obstetric, genital, sexual, and minor procedures (p < 0.001). Female participants, on the other hand, had no preference for emergency surgeries and major surgical procedures (p < 0.001). This study found that participants were more likely to prefer female surgeons for regular non-emergency visits to the surgery clinic (p < 0.001; aOR = 2.344). Additionally, participants had a high preference for female surgeons for sensitive cases (p < 0.001; aOR = 7.064) and minor surgical procedures (p < 0.001; aOR = 2.489).

CONCLUSION

This study underscores the significance of cognizance and the incorporation of a patient's gender preferences when selecting surgical procedures, thus fostering an environment that is more accommodating and focused on the patient.

Predictors for Prolonged TE-to-Implant Exchange During Implant-Based Breast Reconstruction: A Single Institution Experience

BACKGROUND

There is limited evidence regarding the factors causing a prolonged time for tissue expander (TE) exchange into a definitive implant using two-stage implant-based breast reconstruction (IBBR). This study aimed to review our experience with IBBR, focusing on the time for TE-to-implant exchange and determining which factors cause a prolonged time for exchange.

METHODS

A retrospective review was performed to include women undergoing immediate two-stage IBBR with TEs after total mastectomy between January 2011 and May 2021. Reconstructions with irradiated TEs were excluded. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange longer than 232 days, which corresponds to the 75th percentile of the overall study group.

RESULTS

We included 442 reconstructions in our analysis. The median age for our series was 51 years and the median body mass index was 26.43-kg/m2. The median time for TE-to-implant exchange was 155 days [IQR, 107-232]. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange on postoperative day 232 or afterward. Diabetes (OR 4.05, p = 0.006), neoadjuvant chemotherapy (OR 2.76, p = 0.006), an increased length of stay (OR 1.54, p = 0.013), and a lengthier time to complete outpatient expansions (OR 1.018, p < 0.001) were independently associated with a prolonged time for exchange.

CONCLUSION

As evident from our analysis, the time for exchange is highly heterogeneous among patients. Although several factors affect the timing for TE-to-implant exchange, efforts must be directed to finalize outpatient expansions as soon as possible to expedite the transition into a definitive implant.

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 .

"No-back-scar" Latissimus Dorsi Muscle Flap and Tissue Expander: A Valuable Strategy for Secondary Breast Reconstructions

An overall complication rates for implant-based breast reconstruction (IBBR) have been reported from 29 to 46%, particularly in the setting of adjuvant radiotherapy. Although the majority of the literature describes autologous conversion in such scenario, a microsurgical flap is not always feasible. The aim of the paper is to assess surgical and patient-reported outcomes of breast reconstruction using a Latissimus Dorsi muscle Flap (LDMF), harvested without a back scar, in combination with a tissue expander for a two-staged reconstruction in the setting of a previously failed IBBR. All consecutive patients undergoing a two-stages LDMF IBBR between January 2016 and June 2020 were retrospectively identified. A minimal length vertical incision along the posterior axillary line was used for LD flap harvest. Demographic, clinical and surgical data were collected. Aesthetic outcome was evaluated with the Aesthetic Item Scale, and BREAST-Q was used to assess patients' reported outcomes. Twenty-one patients met the inclusion criteria. Mean age was 45.6 years, and the average follow-up was 41.2 months after tissue expander replacement with definitive implant. All patients completed the secondary reconstructive procedure, without major complications both at reconstructive and donor flap site. All women reported to be very satisfied with the final breast reconstruction. Second-attempt implant-based breast reconstruction for patients with a previously failed IBBR is challenging. A conversion from prosthetic to a mixed breast reconstruction with a "no-back scar" LD flap and tissue expander can be considered as a valuable strategy, especially when an abdominal-based autologous breast reconstruction is not feasible or refused by the patients.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 .

Major Clinical Adverse Events of Breast Implant in the Manufacturer and User Facility Device Experience Database

OBJECTIVE

Search the Manufacturer and User Facility Device Experience database to collect information on adverse events of breast implant. We analyzed the local complications and the breast implant illness (BII) of silicone breast implants, as well as saline breast implants separately, aim to provide a reference for women who want to breast augmentation.

MATERIALS AND METHODS

The Manufacturer and User Facility Device Experience database was queried for events reports related to the breast implant between July 1, 2012, and June 30, 2022. Event year and reporting year were summarized. Patient problem was collected and analyzed to distinguish between local complications and BII.

RESULTS

A total of 108,728 adverse events in the past 3 years were analyzed, silicone breast implants accounted for 62.1% and saline breast implants accounted for 37.9%. The most common local complication of women receiving silicone breast implants was "Capsular Contracture," accounting for 48.73%. However, the incidence of "capsular contracture" in women who received saline breast implants was only 17.49%. The most common BII was "fatigue/weakness" in both women receiving 2 different breast implants, 17.20% in women receiving silicone breast implants and 24.71% in women receiving saline breast implants. Of note, in all the reports, there was a wide variation in the timing of reporting as compared with the timing of the adverse event.

CONCLUSIONS

Although the adverse events of breast implant cannot completely be determined from this study, we provide a reference for women who want to get breast implants, so that they can choose breast implants more carefully. In addition, a better understanding of BII may allow them to think further about whether the benefits of breast implants outweigh the risks.

Skin perfusion and oxygen saturation after mastectomy and radiation therapy in breast cancer patients

The pathophysiological mechanism behind complications associated with postmastectomy radiotherapy (PMRT) and subsequent implant-based breast reconstruction are not completely understood. The aim of this study was to examine if there is a relationship between PMRT and microvascular perfusion and saturation in the skin after mastectomy and assess if there is impaired responsiveness to a topically applied vasodilator (Methyl nicotinate - MN). Skin microvascular perfusion and oxygenation >2 years after PMRT were measured using white light diffuse reflectance spectroscopy (DRS) and laser Doppler flowmetry (LDF) in the irradiated chest wall of 31 women with the contralateral breast as a control. In the non-irradiated breast, the perfusion after application of MN (median 0.84, 25th-75th centile 0.59-1.02 % RBC × mm/s) was higher compared to the irradiated chest wall (median 0.51, 25th-75th centile 0.21-0.68 % RBC × mm/s, p < 0.001). The same phenomenon was noted for saturation (median 91 %, 25th-75th centile 89-94 % compared to 89 % 25th-75th centile 77-93 %, p = 0.001). Eight of the women (26%) had a ≥10 % difference in skin oxygenation between the non-irradiated breast and the irradiated chest wall. These results indicate that late microvascular changes caused by radiotherapy of the chest wall significantly affect skin perfusion and oxygenation.

The SAEORA Flap for Prosthetic Breast Reconstruction: A Novel Flap Design without the Use of Acellular Dermal Matrices

Background

The gold standard for implant-based breast reconstruction uses acellular dermal matrices (ADMs). They provide improved inferolateral pole coverage, reduced capsular contracture rates, and increased primary expander fill volumes. However, ADMs are costly and have been associated with increased rates of postoperative infection, seroma, hematoma, implant malposition, and mastectomy flap necrosis (MFN). This study describes a novel autologous flap without the need of ADM, the serratus anterior external oblique rectus abdominis (SAEORA) flap, as an alternative in prosthetic-based breast reconstruction.

Methods

A retrospective study was conducted on all patients who underwent SAEORA flap breast reconstruction by a single surgeon between January 1, 2013 and May 31, 2020 at a single institution. Patient demographics, diagnosis, treatment, tissue expander (TE) volume, implant size, complications, and results were assessed.

Results

Forty-seven patients underwent 78 SAEORA flaps. Sixty-two had TEs placed, and 14 were direct-to-implant. Mean body mass index was 23.1 kg per m². Median primary TE fill volume was 150 mL, and final implant volume average was 450 mL. Mean follow-up was 14.5 months. Complications included infection/cellulitis (7.9%), seroma (6.6%), hematoma (5.2%), and MFN (7.9%).

Conclusions

The SAEORA flap is a novel autologous flap and is a viable option for prosthetic-based breast reconstruction, with an acceptable complication profile relative to ADM-based reconstructions. Additionally, SAEORA is MFN-resistant and has been used effectively in salvage of exposed implants or ADM, and in double-bubble deformity correction.

Early Complications after Prepectoral Tissue Expander Placement in Breast Reconstruction with and without Acellular Dermal Matrix

BACKGROUND

Prepectoral breast reconstruction has become popularized with the concurrent use of acellular dermal matrix (ADM). The authors sought to compare 3-month postoperative complication rates and explantation rates for first-stage, tissue-expander-based, prepectoral breast reconstruction with and without the use of ADM.

METHODS

A single-institution retrospective chart review was performed to identify consecutive patients undergoing prepectoral tissue-expander-based breast reconstruction from August of 2020 to January of 2022. Chi-square tests were used to compare demographic categorical variables, and multiple variable regression models were used to identify variables associated with 3-month postoperative outcomes.

RESULTS

The authors enrolled 124 consecutive patients. Fifty-five patients (98 breasts) were included in the no-ADM cohort and 69 patients (98 breasts) were included in the ADM cohort. There were no statistically significant differences between the ADM and no-ADM cohorts with regard to 90-day postoperative outcomes. On multivariable analysis, there were no independent associations between seroma, hematoma, wound dehiscence, mastectomy skin flap necrosis, infection, unplanned return to the operating room, or explantation in the ADM and no-ADM groups after controlling for age, body mass index, history of diabetes, tobacco use, neoadjuvant chemotherapy, and postoperative radiotherapy.

CONCLUSIONS

The authors' results reveal no significant differences in odds of postoperative complications, unplanned return to the operating room, or explantation between the ADM and no-ADM cohorts. More studies are needed to evaluate the safety of prepectoral, tissue expander placement without ADM.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis

Background: In the past few decades, there has been a gradual increase in breast reconstruction post mastectomy; however, there exists a conflict about whether race has an influence on reconstruction rates. Methods: We conducted an electronic search from MEDLINE and Cochrane CENTRAL from their inception to September 2022. Primary outcome was disparity in rates of Immediate Breast Reconstruction (IBR) in racial minorities. Odds ratios were pooled using a random-effects model. All statistical analyses were performed on the Review Manager. Quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklist. Results: Twenty studies (n = 1 840 671) were identified. The pooled analysis of all the studies showed that subjects in racial minorities were significantly less likely to receive IBR as compared to White subjects (OR = 0.62, [95% confidence interval: 0.57-0.68; P < .01, I 2 = 97%]. Subgroup analyses revealed that Asian subjects were the least likely to undergo IBR among different minorities (OR = 0.43). Conclusion: There exists a significant disparity in rates of IBR in different racial minorities as compared to White subjects. Future studies are warranted to assess factors contributing to such disparities in provision of healthcare.

Revision Breast Reconstruction With Biologic or Synthetic Mesh: An Analysis of Postoperative Capsular Contracture Rates

Background

Both biologic and synthetic mesh have been found to reduce the risk of capsular contracture, yet there is limited data assessing the use of these scaffold materials in revision breast reconstruction.

Objectives

This investigation sought to assess the ability of either biologic or synthetic mesh to prevent capsular contracture in the revision breast reconstruction population.

Methods

A retrospective chart review was conducted of implant-based revision reconstructions performed by the senior author between 2008 and 2023. Patient demographics and outcomes were assessed, including the incidence of Baker Grade III or IV capsular contractures. Results were compared between biologic and synthetic mesh groups using univariate and multivariate analysis.

Results

Ninety-five breasts underwent revision reconstruction with 90 (94.7%) for correction of malposition, 4 (4.2%) for size change, and 1 (1.1%) for revision after additional oncologic breast surgery. Of these breasts, 26 (27.4%) used biologic mesh and 69 (72.6%) used synthetic mesh. Capsular contracture occurred in 1 (3.8%) biologic mesh breast and 4 (5.8%) synthetic mesh breasts. There was no significant difference in the incidence of capsular contracture between the 2 groups (P = 1.000). None of the recorded demographics were risk factors for capsular contracture, including the use of biologic or synthetic mesh (P = .801).

Conclusions

Both biologic and synthetic mesh are successful at preventing capsular contracture in patients undergoing implant-based revision reconstruction. This adds to the growing evidence that both scaffold materials can be used in complex revision breast reconstruction to aid in preventing capsular contracture.

Level of Evidence 4

Integrated Electronic Health Record of Multidisciplinary Professionals Throughout the Cancer Care Pathway: A Pilot Study Exploring Patient-Centered Information in Breast Cancer Patients

Purpose

The aim of this pilot study was to first aggregate and then integrate the medical records of various healthcare professionals involved with breast cancer patients to reveal if and how patient-centered information is documented in multidisciplinary cancer care.

Patients and Methods

We aggregated 20 types of medical records from various healthcare professionals such as physicians, nurses and allied healthcare professionals (AHPs) throughout three breast cancer patients' care pathways in a department of breast surgery at a university hospital. Purposeful sampling was used, and three cases were examined. The number of integrated type of records was 14, 14, 17 in case 1, 2 and 3, respectively. We manually annotated and analyzed them exploratively using a thematic analysis. The tags were produced using both a deductive template approach and a data-driven inductive approach. All records were then given tags. We defined patient-centered information related tags and biomedical information related tags and then analyzed for if and how patient-centered information was documented.

Results

The number of patient-centered information related tags accounted for 30%, 30% and 20% of the total in case 1, 2 and 3, respectively. In all cases, patient-centered information was distributed across various medical records. The Progress Note written by doctors provided much of the patient-centered information, while other records contained information not described elsewhere in the Progress Notes. The records of nurses and AHPs included more patient-centered information than the doctors' notes. Each piece of patient-centered information was documented in fragments providing from each of the healthcare professionals' viewpoints.

Conclusion

The documented information throughout the breast cancer care pathway in the cases examined was dominated by biomedical information. However, our findings suggest that integrating fragmented patient-centered information from various healthcare professionals' medical records produces holistic patient-centered information from multiple perspectives and thus may facilitate an enhanced multidisciplinary patient-centered care.

Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence

For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.