Scientific Abstract Presentations: Breast 2 Thursday, October 26 Thu, Oct 26 3:00-4:30 p.m. CDT

Purpose Breast reconstruction using implants can be done in two ways: single-stage direct-to-implant (DTI) or two-stage using a tissue expander (TE). However, fixed costs and post-operative complications can result in a substantial financial burden. In this study, we aim to compare the direct costs of DTI and TE implant-based breast reconstruction (IBBR) to determine their relative financial burden and identify the factors that affect the cost.

Methods A retrospective chart review and analysis of specific cost data provided by institutional finance department of patients who underwent implant-based BR was conducted to evaluate differences in costs of episode of care (EOC). Multivariable regression analysis and one-way sensitivity analysis were conducted to determine key price drivers for each operation. Statistical analyses were conducted with t-tests, Poisson distribution comparisons and Chi-Square/Fisher Exact Tests.

Results Two hundred and five patients (310 breasts) undergoing DTI (n = 167, 54%) or TE (n = 143, 46%) were evaluated over their entire EOC. The mean follow-up period was 1.6 ± 1.24 years for the DTI cohort and 2.14 ± 1.22 years for the TE cohort (p < 0.001). The DTI cohort had a lower rate of major complications (13% to 22%, p = 0.033) but similar rates of aesthetic revisions (18% to 19%, p = 0.835). The average cost of a DTI EOC ($13,719.39 ± $5,499) was found to be significantly lower than for TE patients ($16,589.54 ± $6,586.95, p < 0.001), with lower operative costs ($10,460.2 ± $4,059.81 and $12,242.87 ± $4,403.81, p = 0.002) and number of postoperative follow-up visits (13.27 ± 7.76 and 23.03 ± 9.05 , p < 0.001). There were no differences in operative costs from complications and aesthetical revisions. The cost of an average DTI EOC is most sensitive to the rate of bilateral operations. For TE, the EOC is most sensitive to the incorporation of acellular dermal matrices.

Conclusion DTI BR incurs lower cost over an EOC compared to TE surgery, likely due to greater planned operative costs and number of postoperative follow-ups. Both operations shared similar complication rates and aesthetic outcomes.

Background: A large majority of implant-based breast reconstructions (IBBR) are performed in two-stages, first placing a tissue expander (TE), then exchanging to an implant. TE infections can be devastating to the reconstructive process and may add to the cost of reconstruction. We examine the salvage rate for infected TEs at our institution and assess variables associated with reconstructive outcomes in managed cases of infection. Methods: We retrospectively reviewed patients who underwent TE placement from 2017 to 2022. Patients were included if they had clinical signs or symptoms of infection within 1 year of TE placement. They must also have received treatment with either intravenous (IV) antibiotics, interventional radiology (IR) drainage, or operative management. Patients solely treated with oral antibiotics were excluded. We identified five management groups: 1) treatment with IV antibiotics only 2) IR drainage 3) TE removal and replacement with a new TE 4) TE removal and replacement with an implant 5) TE removal without replacement. Patients were followed for 1 year after TE placement to assess their reconstructive outcome. Results: 4619 female patients had TEs placed in the examined time frame, of which 347 had an infection within 1 year (7.5%). Factors associated with TE infection included age, BMI, comorbid hypertension and diabetes, radiation, reconstruction timing (immediate versus delayed), ADM, TE pocket (prepectoral versus subpectoral), and average mastectomy weight. 36 patients were excluded because they were managed with oral antibiotics or their operative management did not disturb the previously placed TE. Consequently, 311 patients with infected TEs were evaluated: 115 in treatment group 1, 42 in group 2, 28 in group 3, 18 in group 4, and 108 in group 5. There was a 54% failure rate (167/311) within 1 year for patients with managed cases of infected TEs. 108 of these patients had their TE removed during admission and thus failed during infection management; however 59 displayed improvement for discharge but subsequently lost their reconstruction at a later date. The most favorable rates of success occurred in the replacement with implant cohort, where only 11% of patients failed within 1 year (2/18). This was followed by the IV antibiotic cohort at 24% (28/115). Patients treated with IR intervention had the highest 1-year failure rate at 45% (19/42). For patients who failed reconstruction, the median survival time of the reconstruction was 240 days (7.9 months). There were significant differences between groups in race, infection management plan, and cultured bacteria when assessing patients by reconstructive outcome. 68% of patients had a culture taken from the breast pocket or fluid, and when evaluating reconstructive outcome by gram stain, success was not favorable in patients who grew gram negative organisms. Conclusion: All efforts should be made to limit prosthesis infection as patients who undergo IBR have a greater chance of reconstructive failure than success following infection. For patients who end up with an infectious picture, rather than sending patients to IR, surgeons should consider IV antibiotics or TE removal with replacement by another prosthesis, as salvage rates are higher

Abstract Purpose : BMI cutoffs for breast reconstruction can vary across providers. The purpose of this study was to describe an optimal BMI threshold for breast reconstruction using a large national database. Methods : The 2010 to 2020 National Surgical Quality Improvement Program (NSQIP) was queried for patients who underwent both autologous and implant based breast reconstruction. A multivariable logistic regression analysis was used to determine any significant preoperative predictors of either wound or venous thromboembolism (VTE) complication, and patients with the predictive characteristics were excluded from analysis. A receiver operating characteristic (ROC) curve and subsequent Youden Index (J) was used to determine optimal BMI thresholds for wound and VTE complications within each surgery cohort. Results : A total of 13,087 patients were included in the autologous cohort for wound complication, 724 (5.5%) of which were found to have wound complications. The BMI cutoff, as determined by the maximum J value (Jmax), was 29.0. In the autologous cohort for VTE complication 20,869 patients were included, and a total of 226 (1.1%) VTE complications were reported. The Jmax was 29.3. Overall, 58,734 patients were included in the implant cohort for wound complications. Within this cohort, 1836 (3.1%) wound complications were found, and the Jmax was 27.8. The implant cohort for VTE complications consisted of 90,924 patients with a total of 285 (0.3%) VTE complications. Jmax was 30.0. Conclusion: Our data indicates that optimal BMI cutoffs after AR and IR procedures vary based on procedure and complication category with the majority of BMI thresholds found to be at the border of Overweight (25 - 29.99) and Obesity Class 1 (30 - 34.99). These cutoff values can be used as a tool to guide surgical risk assessment and discussions of safety.

Introduction: Following mastectomy, patients often experience loss of breast sensation. The return of sensation commonly takes time and depends on a variety of factors, including patient comorbidities, breast size, mastectomy type, and method of reconstruction. Quality of life (QoL) in patients after mastectomy has been well studied and tends to decline in the context of changes to usual appearance, post-operative complications, and the psychologic stressors of undergoing oncologic treatments. However, few studies have examined the relationship between quantitative breast sensation and patient wellbeing after mastectomy and reconstruction. The goal of this study is to measure the impact of breast sensation on QoL in patients who underwent nipple sparing mastectomy with alloplastic or autologous reconstruction.

Methods: Patients undergoing mastectomy with implant-based or deep inferior epigastric perforator (DIEP) flap reconstruction were identified and prospectively followed at pre- and post-operative timepoints. Neurosensory evaluation was performed in 9 breast regions, utilizing a pressure-specified sensory device to determine 1 point-static cutaneous thresholds (range: 0 – 100 g/mm^2). At these same timepoints, the BREAST-Q reconstruction module, an externally validated patient-reported outcome measure, was administered. Patients were stratified by reconstructive method and time from mastectomy. Univariate linear regression models were used to measure the correlations between quantitative average sensory measurements and BREAST-Q physical wellbeing, psychosocial wellbeing, sexual wellbeing, and breast satisfaction scores (alpha=0.05).

Results: 109 patients met the inclusion criteria for this study. 85 patients underwent bilateral reconstruction, and 21 patients underwent neurosensory testing and survey administration at multiple timepoints, accounting for a total of 218 breasts. Patients were followed for an average of 30 months after mastectomy (range: 3 – 311 months). 102 breasts underwent alloplastic reconstruction and 116 received autologous DIEP flap reconstruction. Preoperatively, breast sensation was significantly associated with higher self-reported psychosocial and sexual wellbeing. Linear regression revealed that for every 1 g/mm^2 decrease in sensation threshold, psychosocial wellbeing scores increased by 0.27 and sexual wellbeing scores increased by 0.37. A similar association was seen post-operatively in patients who underwent DIEP flap reconstruction, with improved sensation correlating with higher self-reported psychosocial and sexual wellbeing (coef: 0.15 and 0.20, respectively). In these patients, improved sensation was also significantly associated with higher overall breast satisfaction (coef: 0.25). For patients who underwent implant-based reconstruction, significant correlations between breast sensation and breast satisfaction, psychosocial, sexual, or physical wellbeing were not seen.

Conclusion: Prior to mastectomy and reconstruction, breast sensation is positively correlated with quality of life, particularly in terms of psychosocial and sexual wellbeing. Following autologous DIEP reconstruction, the significant association between improvement in breast sensation and higher self-reported quality of life in these domains continues to be seen. Therefore, surgical techniques that target improvement in breast sensation should be employed to improve patient quality of life postoperatively. Further follow-up is needed to appreciate the long-term impact of postoperative return of sensation and method of reconstruction on patient wellbeing.

Introduction: Oncoplastic breast reduction (OBR) combines lumpectomy with reduction mammoplasty to provide effective tumor resection while achieving aesthetic surgical outcomes. However, combining lumpectomy with breast reduction may increase perioperative risks. Our goal was to understand if oncoplastic reduction confers a higher operative risk profile than bilateral breast reduction (BBR) alone. Methods: Patients from the National Surgical Quality Improvement Program (NSQIP) were identified by appropriate codes (19318 for BBR, 19301 or 19302 with 19318 for OBR). Demographics, preoperative comorbidities, and postoperative complications were extracted and analyzed with univariate and multivariate regressions. Results: A total of 40,618 patients were included (BBR n=38,461, OBR n=2157). Compared to BBR patients, OBR patients were older (54.5 vs 41.1), more frequently Caucasian (63.3% vs 44.2%), with a higher BMI (32.4 vs 30.9), more medical comorbidities (10.9% DM, 37.2% HTN), and worse ASA (33.6% with score >2). OBR patients had higher rates of all complications (8.2% v 6%, p<0.001), reoperation (2.5% v 1.5%, p<0 .001), and readmission (2.5% v 1.3%, p <0.001). When controlling for confounding variables in multivariate regression, OBR predicted higher reoperation and readmission at 30 days.

Conclusion: Patients undergoing OBR have higher rates of reoperation and readmission than BBR, likely due to the combination of greater comorbidities and additional surgical burden. When controlling for preoperative characteristics, OBR was not an independent predictor of total complications. OBR patients were also significantly more frequently white when compared to BBR patients, which may reflect disparities in access to care.

Introduction: Autologous breast reconstruction rates have been increasing due to associations with fewer reconstructive failures, decreased hospital readmission rates, and higher BREAST-Q scores, relative to prosthetic techniques. However, previous studies suggest that Black patients and those with public insurance are less likely to undergo autologous reconstruction.1,2 The aim of this study was to characterize the relationship of insurance type with complication rates and patient reported outcome measures (PROMs) after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. We hypothesize that there will be greater complication rates and lower PROM scores in patients with public insurances.

Methods: A single-center, retrospective analysis of patients who underwent postmastectomy immediate, autologous DIEP flap breast reconstruction between January 2010 and December 2020 was performed. Types of insurances were categorized into commercial, Medicaid, Medicare. PROMs were measured by the five main domains of the BREAST-Q. A minimal clinically important difference of 4 points was used to determine clinical significance.

Results: A total of 674 patients who underwent immediate, autologous DIEP flap breast reconstruction were included. A majority of patients (78.8%) had commercial insurance, followed by Medicare (15.3%) and Medicaid (5.9%). There were significant differences in median age, ethnicity, marital status, median household income, and receipt of radiation by insurance type.

There was a significant association between insurance type and complications following DIEP flap. Patients with Medicaid (32%) were significantly more likely to experience cellulitis/abscess than patients with Medicare (21%) or commercial insurance (15%) (p=0.024). Notable differences between insurance types were observed in delayed healing (p=0.052), flap compromise (p=0.058), and seroma rates (p=0.059). Patients with commercial insurance had significantly greater long-term physical well-being of the chest. At 2 years postoperatively, patients with commercial insurance had a median score of 80 (68, 92) while Medicare patients had a median score of 76 (63, 91) and those with Medicaid had a median score of 60 (54, 72) (p=0.013).

Conclusion: Patients with commercial insurance are less likely to experience some types of perioperative complications, including cellulitis/abscess, delayed healing, flap compromise, and seroma, than those with public insurance. These patients also have significantly higher physical well-being of chest scores at 2 years. Further work should be conducted to assess the underlying reasons for these discrepancies in complication rates and patient-reported outcomes depending on insurance status including socioeconomic determinants of care.

References: 1. Boyd LC, Greenfield JA, Ainapurapu SS, Skladman R, Skolnick G, Sundaramoorthi D, Sacks JM. The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States. Plast Reconstr Surg Glob Open. 2023 Feb 17;11(2):e4818. doi: 10.1097/GOX.0000000000004818. PMID: 36817274; PMCID: PMC9937099. 2. Restrepo DJ, Huayllani MT, Boczar D, Sisti A, Nguyen MT, Cochuyt JJ, Spaulding AC, Rinker BD, Perdikis G, Forte AJ. Disparities in Access to Autologous Breast Reconstruction. Medicina (Kaunas). 2020 Jun 8;56(6):281. doi: 10.3390/medicina56060281. PMID: 32521732; PMCID: PMC7353892.

Background: Patients undergoing mastectomy may benefit from microsurgical techniques for lymphedema prevention, such as lymphatic microsurgical preventive healing approach (LYMPHA), or lymphedema treatment, such as lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT). Since these are relatively novel procedures with limited cost-effectiveness data and variable insurance coverage, we sought to elucidate trends and payments for microsurgical lymphedema procedures at a state-wide level.

Methods: We queried the Massachusetts all-payer claims database for patients undergoing mastectomy for a predisposition to or diagnosis of breast cancer between 2016 and 2020. Among those, we identified patients with claims for LYMPHA, LVB, and/or VLNT. Using previously described billing codes [1], we identified patients with claims for LYMPHA or LVB (CPT code: 38308) and VLNT (CPT: 38999, 15756, 15758) on the same date of service as mastectomy (synchronous) or after mastectomy (asynchronous). We quantified annual trends in the use of microsurgical lymphedema interventions and their associated payer and out-of-pocket patient costs, comparing privately- and publicly-insured patients.

Results: A total of 8099 patients had mastectomy claims between 2016-2020. Of these, 77 (1.0%) unique patients had claims for LYMPHA, LVB, and/or VLNT. The relative proportion of total lymphedema procedure claims per the number of mastectomy claims per year increased over time (2016: 0.3%, n = 5; 2017: 0.9%, n = 15; 2018: 1.1%, n = 19; 2019: 1.2%, n = 21; 2020: 2.6%, n = 38). Regarding LVB or LYMPHA (n = 27), 21 (77.8%) procedures were synchronous and 6 (22.2%) procedures were asynchronous. Regarding VLNT (n = 69), 39 (56.5%) procedures were synchronous and 30 (43.5%) were asynchronous. Of those who underwent any lymphedema procedure, 25% (n = 19) were publicly insured and 75% (n = 58) were privately insured. Mean out-of-pocket patient costs for LVB or LYMPHA were $471 (public) and $1110 (private) when synchronous and $0 (public) and $580 (private) when asynchronous. Mean payer costs for LVB or LYMPHA were $206 (public) and $290 (private) when synchronous and $562 (public) and $790 (private) when asynchronous. Mean out-of-pocket patient costs for VLNT were $15637 (public) and $4326 (private) when synchronous and $0 (public) and $6957 (private) when asynchronous. Mean payer costs for VLNT were $3410 (public) and $6426 (private) when synchronous and $3020 (public) and $8593 (private) when asynchronous.

Conclusion: Physiologic lymphedema procedures have increased over time in the state of Massachusetts and nationwide. There is considerable variability in both payer and out-of-pockets patient costs, for both synchronous and asynchronous procedures. Costs tended to be higher for privately insured patients. More cost-effectiveness studies and greater standardization in the care pathways and billing practices for microsurgical lymphedema procedures are needed.

1. Johnson AR, Asban A, Granoff MD, et al. Is Immediate Lymphatic Reconstruction Cost-effective?. Ann Surg. 2021;274(6):e581-e588. doi:10.1097/SLA.0000000000003746

Purpose: While many surgeons prefer one pedicle type for breast reductions, there is no evidence for the optimal pedicle type or which is best suited for certain patients. Here, we utilize photographic analysis to examine the impact of pedicle type on aesthetic outcomes after reduction mammaplasty.

Methods: Preoperative and postoperative photographs (average 4.25 months postoperatively) were taken from 100 randomized patients from 6 surgeons at a single institution. Clinical data was extracted retrospectively from the patient's medical record. 10 non-experts (medical students) rated photographs in a blinded review using the 13-item Validated Breast Aesthetic Scale, which includes ratings regarding breast and nipple areolar complex (NAC) position, shape, and symmetry. Mean scores were calculated and patients were stratified by pedicle type. Univariate analysis was performed.

Results: 60 breast reductions were performed using an inferior pedicle and 40 using a superior or superomedial pedicle. Inferior pedicle patients were more likely to be obese (p=0.0222), have greater ptosis (p=0.0014), poor skin quality (p=0.0167), and a greater volume of tissue resected (p=0.0024). Clinical outcomes were similar across groups. Breast position was rated more favorably in the superior pedicle group (p=0.035). Scar appearance, NAC projection, and NAC shape were rated higher in the inferior pedicle group (p=0.0325, p=0.0184, and p=0.0708, respectively).

Conclusion: Pedicle type was not associated with complication rate. Inferior pedicles were used more frequently for more obese patients and larger breast volumes. Superior pedicles were associated with better breast position while inferior pedicles were associated with better NAC position and shape.

Background: In the United States, breast cancer accounts for more than 1 in 7 cancer diagnoses, with genetic predisposition being a well-known risk factor. While some patients elect to undergo prophylactic mastectomy, there is a lack of insight into the factors influencing the decision to undergo prophylactic intervention. The objective of our study is to better understand the timing and social factors influencing decision to pursue prophylactic mastectomy with or without reconstruction in patients with a genetic predisposition for breast cancer.

Methods: This study is a retrospective review of patients diagnosed with genetic predisposition for breast cancer from August 2016 to December 2020. The electronic medical record was used to collect information regarding patient demographics, oncologic, and surgical history. Patients were separated into categories based on whether they underwent prophylactic surgical intervention and if this was followed by reconstructive surgery. Diagnosis, oncologic surgery, and reconstruction dates were all noted. Descriptive statistics were conducted to understand social factors and simple t-tests were used to compare time to surgical intervention among groups.

Results: 255 patients with genetic predisposition for breast cancer were included. Of these, 56 patients (22.0%) underwent prophylactic mastectomy; 74.5% of these patients underwent subsequent post-mastectomy reconstruction. 98% of prophylactic mastectomy patients were Caucasian, as were all patients undergoing post-mastectomy reconstruction. All patients were female with an average age of 44 years (SD 15.7) at the time of high-risk diagnosis. The greatest percent of patients had a BRCA2 mutation (33.7%) followed by BRCA1 (25.8%), CHEK2 (20.6%), and ATM (12.7%). However, 74.6% of people undergoing prophylactic mastectomy had a BRCA1 or 2 mutation. Median time from diagnosis of genetic predisposition to time of mastectomy was 1.2 years (range 0.07-6.5 years). Among patients undergoing reconstruction, 82% of patients underwent immediate reconstruction, with 87% of patients having an implant-based breast reconstruction. When comparing patients with and without reconstructive surgery, there was no significant difference in time from diagnosis to time to mastectomy (p>0.05).
The most common social factor impacting the patient's decision to undergo prophylactic surgery was having a family member with a cancer diagnosis (54.7%). Other social factors that patients noted during their clinic visits were a personal cancer diagnosis (27.5%), most commonly ovarian or thyroid, immediate family member death (6.8%), and pregnancy or completion of childbearing years (3.2%).

Conclusion: Through this study we found that women most commonly elect to undergo prophylactic surgery within two years of their own diagnosis, and that the factor most commonly influencing this decision is cancer diagnosis in a family member. A better understanding of time from diagnosis to surgery and the social factors that may influence a high-risk patient's decision to undergo prophylactic surgery will further inform patient counseling and shared decision-making during preoperative reconstructive consultations.

PURPOSE: Tissue expander-based breast reconstruction is associated with high rates of infectious complications. This often leads to tissue expander explant and subsequent delays in receipt of definitive breast reconstruction and adjuvant therapy. As such, our aim was to describe and validate a novel strategy to salvage infected tissue expanders and complete definitive reconstruction in a single stage.

METHODS: In this IRB-approved study, six patients were included who underwent a single-stage surgery in which DIEP flaps were used to salvage actively infected tissue expanders. This technique involved maintaining patients with subclinical tissue expander infections on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant was performed in conjunction with a subtotal capsulectomy, debridement, intra-operative cultures, and immediate DIEP flap reconstruction. Postoperatively, patients were maintained on 1-2 weeks of oral antibiotics tailored to culture data. Demographic, oncologic, and reconstruction characteristics were collected for all patients. The primary outcome of interest was postoperative complications after conversion to DIEP flap.

RESULTS: Six patients with culture-proven tissue expander (TE) infections underwent TE explant and DIEP flap reconstruction in a single stage in accordance with our protocol. Four patients (66.7%) had infected pre-pectoral tissue expanders and two (33.3%) had infected partial submuscular expanders. ADM was used in every case. Four patients (66.7%) required outpatient aspiration and cultures prior to their DIEP flap surgeries. An average of 38.8 days (SD = 20.4) elapsed from documented infection to definitive free flap surgery. Intra-operative cultures grew Staph aureus (33.3%), Staph epidermidis (33.3%), Enterobacter cloacae (16.7%), and mixed gram-positive organisms (16.7%). Mean post-op length of stay was 3 days. Within this cohort, no post-operative complications were noted within a 90-day period, including surgical site infections requiring PO or IV antibiotics, seroma, hematoma, microvascular complications, partial flap losses, reoperations, or returns to the operating room (0%).

CONCLUSIONS: Our data suggests that actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery, with low incidence of post-operative complications including surgical site infection. This treatment strategy provides a significant opportunity to reduce costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander-related infection.

Background: Breast reconstruction is a vital aspect of breast cancer treatment, providing significant improvements to quality of life for patients who have undergone mastectomy. While postmastectomy radiation therapy (PMRT) also plays a pivotal role in treatment for many patients, its benefits often come at the cost of compromising breast reconstruction outcomes. As such, identifying approaches that optimize reconstructive outcomes is of particular importance in this population.

Methods: We conducted a retrospective chart review of consecutive patients who underwent postmastectomy breast reconstruction at a single institution. Eligible patients were those who received PMRT, and data collected included patient demographics, comorbidities, operative details, and postoperative complications. The primary outcomes assessed were mastectomy skin flap necrosis (MSFN) and reconstruction failure, defined as the removal of the tissue expander or implant due to any complication. Reconstruction failure specifically due to infection was also collected.

Results: Among the 684 patients initially identified, 156 met the inclusion criteria for the study. Skin-sparing mastectomies were the most common approach used in this cohort (57%), followed by nipple-sparing mastectomies (41%) and skin-reducing mastectomies (2%). The majority of patients underwent prepectoral reconstruction (70%) compared to subpectoral (30%). Mastectomy approach and reconstruction plane were not associated with reconstructive outcomes, whereas comorbidities were significantly associated with complications. Specifically, BMI was associated with an increased incidence of MSFN (p=0.026), while diabetes was associated and positively correlated with both MSFN (p=0.007, r=0.260) and any-cause reconstruction failure (p=0.043, r=0.186). Smoking was also associated and positively correlated with higher rates of any-cause (p=0.043, r=0.186) and infection-specific (p=0.031, r=0.219) reconstruction failure. Furthermore, MSFN was positively correlated with any-cause (r=0.340) and infection-specific (r=0.222) reconstruction failure.

Conclusion: Operative decisions including type of mastectomy and plane of reconstruction did not significantly impact MSFN or reconstruction failure; whereas BMI, diabetes, and smoking were all significantly associated with complications. Our findings highlight the importance of identifying and addressing modifiable risk factors in the preoperative setting in order to optimize reconstruction outcomes in patients receiving PMRT.

Purpose Prepectoral breast reconstruction has seen a resurgence in recent years, in contrast to the more common subpectoral implant placement. Whereas differences in clinical outcomes have been well studied, there is a paucity of data surrounding the economic burden of each respective modality throughout their episode of care (EOC). Here, we compare direct costs of subpectoral and prepectoral IBBR and discern their respective price drivers to better understand their relative financial impact.

Methods A retrospective chart review and analysis of specific cost data provided by institutional finance department of patients who underwent implant-based BR was conducted to evaluate differences in costs of episode of care (EOC). Multivariable regression analysis and one-way sensitivity analysis were conducted to determine key price drivers for each reconstructive plane. Statistical analyses were conducted with t-tests, Poisson distribution comparisons and Chi-Square/Fisher Exact Tests.

Results Two hundred and eleven patients (320 breasts) undergoing IBBR with subpectoral (n = 126, 60%) or prepectoral (n = 85, 40%) placement were studied over their entire EOC. The mean follow-up period was 2.29 ± 1.37 years for the subpectoral cohort and 1.32 ± 0.89 years for the prepectoral cohort (p < 0.001). The subpectoral cohort had a higher rate of aesthetic concerns for asymmetry (2% vs 9%, p = 0.012) and animation deformity (4% to 0%, p = 0.045), but a lower rate of implant rippling (3% to 13%, p < 0.001). However, ultimately these did not lead to a difference in revisional surgery rates. Both cohorts had similar rates of complications with a major complication rate of 14% among the subpectoral group and 21% among the prepectoral group (p = 0.093). The average cost of IBBR with subpectoral placement ($15,042.28 ± 6,425.65) was not significantly different than that with prepectoral placement ($15,914.15 ± 6,379.91, p = 0.333), although there were more postoperative clinical visits among the subpectoral cohort (19.77 ± 10.26 vs 16.02 ± 9.21, p = 0.006). ADM, when used, engendered a higher cost burden to the prepectoral cohort ($4,929.72 ± 2,499.12 vs $7,287.83 ± 3,447.88, p < 0.001). There were no differences in operative costs from complications and revisions for aesthetical concerns. The cost difference was sustained after subgroup analysis by laterality, ADM use, staging of operation and presence/absence of a major complication, all of which were found to be significant cost drivers for the IBBR EOC.

Conclusion Subpectoral and prepectoral IBBR have a similar complication profile and rate of revisional surgery. Importantly, they incur similar costs throughout their EOC. ADM use disproportionately costs more for patients undergoing prepectoral placement of the implant due to requiring increased coverage.

Purpose: Nipple areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander reconstruction. This study assesses the characteristics contributing to NAC necrosis and identifies strategies for mitigating this risk. Methods: A chart review of all consecutive, prepectoral tissue expander reconstructions performed between March 2017 and July 2022 at a single center was conducted. Patients from a total of 5 distinct breast surgeons and 5 plastic surgeons were included. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. A ratio of intraoperative TE fill to mastectomy weight (TEF/MW) was constructed to quantify "deadspace" in the breast pocket, with higher values signifying less deadspace due to a higher TE fill to pocket ratio. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, while total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. The Youden method was used for predicting optimal cut off. A p<0.05 was considered statistically significant. Results: A total of 184 patients (292 breasts) were included, with an average follow up time of 27 months. Women were on average 53 years old, non-smoker (99%), non-diabetic (91%), and had a body mass index (BMI) of 28 kg/m2. All reconstructions were performed immediately after prophylactic mastectomies in 33% and therapeutic mastectomies in 67% of cases. The majority of mastectomies were skin sparing (61%), followed by nipple sparing (24%), simple (12%) and other (3%). Seventy-one (24%) breasts were radiated (77% adjuvant, 20% prior radiation, 3% both), and 89 (48%) patients received chemotherapy (19% adjuvant, 4% neoadjuvant, 1% both). Median mastectomy weight was 551 grams, average intraoperative TE fill was 194 ± 163 cc, and average final TE fill was 416 ± 159 cc. Partial NAC necrosis occurred in 8 (3%) breasts and there were zero instances of complete NAC necrosis. Partial NAC necrosis was associated with lower BMI (21 vs. 28 kg/m2, p<0.001) and lower mastectomy weight (360 g vs. 675 g, p = 0.04). Although partial NAC necrosis was not related to intraoperative TE fill, it was associated with less deadspace in the breast pocket (0.68 TEF/MW vs. 0.38 TEF/MW, p=0.04). Optimal intraoperative TE fill to mastectomy weight ratio for avoiding partial NAC necrosis was 0.31. In multivariable models controlling for age, BMI, mastectomy weight, radiation, and soft tissue support, partial NAC necrosis was associated with lower BMI. For every 1-point increase in BMI, the odds of partial NAC necrosis decreased by 0.67 (95% CI [0.42-1.0], p=0.05). Conclusions: In this study, lower BMI individuals were predisposed to having partial NAC necrosis following prepectoral TE reconstruction. Managing intraoperative TE fill is a difficult clinical challenge as there are competing forces including the dual goals of expediting the expansion process and minimizing deadspace weighed against the deleterious effects of increased tension and pressure and mastectomy flaps. Potential strategies for mitigating the risk of partial NAC necrosis include optimizing the intraoperative TE fill to mastectomy ratio to one-third.