Scientific Abstract Presentations: Breast 3 Thursday, October 26 Thu, Oct 26 5:00-6:00 p.m. CDT

Background: Closed-incision negative pressure wound therapy (ciNPWT) has shown promise in reducing wound complications in many types of surgical procedures.^1-4 Its application allows for exudate management and tension offloading from the wound edges.^5 As a result, it may reduce wound complications at the donor site in autologous breast reconstruction (AR). The purpose of this systematic review and meta-analysis is to assess the efficacy of prophylactic ciNPWT versus conventional dressings on abdominal donor site complications in AR.

Methods: This systematic review was reported according to PRISMA guidelines. PubMed and EMBASE were searched in January 2023 to identify all studies which compared the efficacy of ciNPWT to conventional dressings on abdominal donor site complications in autologous reconstruction. There were no restrictions on the date range inquiry. Included studies were published from 2020 to 2022. Data collected included: rates of total wound complications, wound dehiscence, infection, seroma, and length of hospital stay.

Results: A total of 202 articles were screened and eight studies (1,009 patients) met the inclusion criteria. ciNPWT was associated with a significantly lower rate of wound dehiscence (OR, 0.53; 95% confidence interval, 0.33-0.85; p=0.0085, I^2=0%). There was no significant difference in the rate of total wound complications (OR, 0.63; 95% confidence interval, 0.35-1.14; p=0.12, I^2=69%), donor site infection (OR, 0.91; 95% confidence interval, 0.42-1.50; p=0.47, I^2=13%), seroma (OR, 0.74; 95% confidence interval, 0.22-2.49; p=0.63, I^2=57%), or length of hospital stay (SMD, 0.089; 95% confidence interval, -0.13-0.35; p=0.37).

Conclusions: The prophylactic use of ciNPWT on the abdominal donor site for AR is associated with decreased rates of wound dehiscence compared to conventional dressings. No significant difference was detected in rates of total wound complications, infection, seroma, and length of hospital stay.

References

1. Xie W, Dai L, Qi Y, Jiang X. Negative pressure wound therapy compared with conventional wound dressings for closed incisions in orthopaedic trauma surgery: A meta-analysis. Int Wound J. 2022;19(6):1319-1328. doi:10.1111/IWJ.13726
2. Guo C, Cheng T, Li J. Prophylactic negative pressure wound therapy for closed laparotomy incisions after ventral hernia repair: A systematic review and meta-analysis. Int J Surg. 2022;97. doi:10.1016/J.IJSU.2021.106216
3. Boll G, Callas P, Bertges DJ. Meta-analysis of prophylactic closed-incision negative pressure wound therapy for vascular surgery groin wounds. J Vasc Surg. 2022;75(6):2086-2093.e9. doi:10.1016/J.JVS.2021.12.070
4. Sahebally SM, McKevitt K, Stephens I, et al. Negative Pressure Wound Therapy for Closed Laparotomy Incisions in General and Colorectal Surgery: A Systematic Review and Meta-analysis. JAMA Surg. 2018;153(11). doi:10.1001/JAMASURG.2018.3467
5. Lalezari S, Lee CJ, Borovikova AA, et al. Deconstructing negative pressure wound therapy. Int Wound J. 2017;14(4):649-657. doi:10.1111/IWJ.12658

Background: Rising healthcare costs pose significant concerns for physicians and patients. At baseline, DIEP flaps are a lengthy and expensive process for women seeking breast reconstruction. Access to care has only worsened with recent CMS policy changes and growing gaps in coverage. Despite these challenges, we can evolve our practices to deliver efficient, safe and cost-effective care. Deliberate practice and process analysis have been shown to improve efficiency and complication rates. This study will evaluate its utility in reducing cost, thereby providing greater access to care for women.

Methods: Authors retrospectively reviewed all patients who underwent bilateral DIEP flap reconstruction before, during and after process analysis during a 72-month period. Total Cost was broken down into Fixed Direct, Fixed Indirect and Variable Direct Costs. Individual products and services that were evaluated during an episode include: OR Services, MedSurg Supplies, Anesthesia, Labs, Radiology, Therapy, Pharmacy, Room and Board, Respiratory and Blood. A risk-adjusted logistic regressions analysis was used to determine the impact of the process analysis on cost, operative time and length of stay.

Results: During the 72-month period (April 2015 to May 2021), the senior authors performed bilateral DIEP flaps in 375 patients (750 total flaps) with an average follow-up of 12 months. Length of stay in the process analysis group was decreased by .84 days (p<.001) with an average Room and Board savings of $1,755.16 (p<.001). Operative time in the process analysis group was decreased by 2 hours and 13 minutes (p<.001) with an average MedSurg Supplies savings of $440.71 (p<.001). There were no statistically significant differences among Radiology, Blood, Lab or Pharmacy costs. Therapy costs increased in the process analysis group by $166.63 (p<.001). OR Services and Anesthesia costs increased each year with no differences between groups; however, total cost was less in the process analysis group, with an average savings of $3,881.07 (p<.001) per episode.

Conclusion: Deliberate practice and process analysis are highly associated with safe, improved and cost-effective outcomes. While this analysis is from the hospital's perspective, the decreased hospital stay and cost per episode have clear and significant benefits when translated to the patient.

Citations: Haddock, Nicholas T. MD*; Tycher, John T. BS; Teotia, Sumeet S. MD. Deliberate Practice and Process Analysis in DIEP Flap Breast Reconstruction: An Immediate and Sustained Decrease in Morbidity and Operative Time. Plastic and Reconstructive Surgery ():10.1097/PRS.0000000000010379, March 08, 2023. | DOI: 10.1097/PRS.0000000000010379

The Schnur sliding scale (SSS) is used by many third-party payors to classify reduction mammaplasties as either cosmetic (below the SSS) or reconstructive (above the SSS). Although the SSS was developed using an adult cohort, it is applied to adolescent macromastia patients for whom there has been no validation of its medical utility. This study aims to compare the physical and psychosocial impact of reduction mammaplasty in adolescents above and below the SSS.

Health-related quality of life surveys were administered to patients, 12 to 21 years old, undergoing reduction mammaplasty for macromastia. Surveys included Short Form-36v2 (SF-36), the Rosenberg Self-Esteem Scale (RSES), and the Breast-Related Symptoms Questionnaire (BRSQ). Age and BMI data were collected, and SSS values were determined for each patient. Paired t-tests compared preoperative and postoperative survey scores. Linear regression models, adjusted for BMI, evaluated the impact of undergoing resection greater than or less than the SSS on postoperative survey scores.

The average mass of resected tissue fell below the SSS for 39 patients and above the SSS for 255 patients. Groups featured no difference in mean age or BMI. Both groups had significant postoperative survey score improvements on the RSES, BRSQ, and in 7/8 SF-36 domains: physical functioning, role physical, bodily pain, vitality, social functioning, role emotional, and mental health (P < .05, all). Patients with resected tissue above the SSS had significant postoperative survey score improvement in one additional SF-36 domain (i.e., 8/8 SF-36 domains): general health (P < .05). Postoperatively, both groups scored comparably on all study measures (P > .05, all).

Adolescents undergoing reduction mammaplasty above and below the SSS experienced comparable physical and psychosocial benefits. These findings underscore the need for third-party payers to broaden coverage for adolescent reduction mammaplasty, as the common reimbursement cutoff has minimal impact on overall postoperative benefit.

Purpose: There is a significant gap in managing patient expectations in breast reconstruction. The ability to predict patients' postoperative quality of life using preoperative factors and BREAST-Q scores may allow surgeons to assess patient satisfaction prior to surgery and tailor patient care. However, preoperative BREAST-Q scores are not routinely collected, compared to postoperative scores. The aim of this study is to examine whether different preoperative factors can predict patient satisfaction at 1-year follow up and to quantify the importance of preoperative scores in this prediction model.

Methods: A retrospective analysis of patients who underwent breast reconstruction and completed the BREAST-Q Satisfaction with Breasts at 1-year follow-up between January 2017-December 2021 was included. Preoperative Satisfaction with Breasts score, demographics, and clinical factors were collected. Two multiple linear regression models were fit, one which included preoperative Satisfaction with Breasts (Model 1) and the other which did not (Model 2). For model 1, multiple imputation was used to account for the missing preoperative scores. These models were compared using a likelihood ratio test to assess whether the model with preoperative Satisfaction with Breasts score was a better fit.

Results: A total of 2,324 breast reconstruction patients were included in the analysis. Of these, 1,545 (66%) and 779 (34%) underwent implant-based and autologous-based reconstruction, respectively. Model 1 showed that increased preoperative score (Beta=0.08; 95% CI: 0.03, 0.14; p-value=0.005), autologous reconstruction (Beta=6.1; 95% CI: 3.7, 8.4; p<0.001), and mastectomy weight less than 400 grams (versus 400-799 gm; Beta=3.2; 95% CI: 0.5, 6.0; p=0.021) were associated with increased Satisfaction with Breasts at 1-year follow-up. A history of psychiatric diagnoses (Beta=-3.8; 95% CI: -5.6, -2.0; p<0.001), neoadjuvant radiation (Beta=-5.0; 95% CI: -8.3, -1.7; p=0.003), and increased BMI (Beta=-0.21; 95% CI: -0.43, 0.00; p=0.053) were associated with decreased 1-year Satisfaction with Breasts. After removing the preoperative score variable in Model 2, autologous reconstruction, mastectomy weight < 400 gm (vs. 400-799 gm), BMI, history of psychiatric diagnoses, and radiation remained significantly associated with the postoperative Satisfaction with Breasts. The comparison between Model 1 and Model 2 showed that including preoperative scores significantly improves model fit (Test Statistic=7.47; p=0.008).

Conclusion: Surgeons can predict patients' postoperative Satisfaction with Breasts using certain preoperative factors, such as, preoperative score, reconstruction type, BMI, history of psychiatric diagnoses, receipt of radiation, and mastectomy weight. These factors may help surgeons manage patient expectations even prior to breast reconstruction. Furthermore, we strongly encourage surgeons to routinely collect preoperative BREAST-Q's Satisfaction with Breasts as the preoperative scores are important in predicting postoperative patient satisfaction.

Introduction: Breast anesthesia is a common complaint following mastectomy and reconstruction due to the necessary disruption of sensory nerves. Furthermore, the process of nerve regeneration is slow, causing some patients to experience suboptimal sensation years after the initial reconstruction. The aim of this study is to longitudinally evaluate and compare return in sensation between implant-based and autologous reconstructions, particularly at 2 or more years postoperatively.

Methods: This is a prospective study of all patients who underwent mastectomy and either immediate alloplastic reconstruction with implants or autologous reconstruction with neurotized deep inferior epigastric perforator (DIEP) flaps. All patients were prospectively identified and followed longitudinally. Neurosensory testing was performed in 9 breast regions using a pressure-specified sensory device to determine 1-point static cutaneous thresholds at preoperative and postoperative time intervals. Values were scaled on a 0-100 point range such that higher values indicate increased sensitivity.

Results: A total of 234 patients (709 breasts) were included in the study, of which 130 patients (418 breasts) were in the DIEP cohort and 104 patients (291 breasts) were in the implant cohort. The two cohorts had comparable sensitivity measurements at preoperative baseline (85.9 for DIEP vs 81.7 for implants, p = 0.15). At less than 1 year postoperatively, the DIEP cohort had significantly better sensory return compared to the implant cohort (38.1 for DIEP vs 30.9 for implants, p = 0.018). This trend continued between 1 to 2 years postoperatively (48.3 for DIEP vs 33.1 for implants, p = 0.005). Between 2 to 4 years postoperatively, sensory return returned to comparable levels between the two cohorts (49.9 for DIEP vs 49.6 for implants, p = 0.97). At more than 4 years postoperatively, patients in the DIEP cohort ultimately had better sensory recovery compared to the implant cohort (62.2 for DIEP vs 48.7 for implants, p = 0.004).

Conclusions: On a longitudinal scale, neurotized autologous reconstruction confers superior sensory recovery compared to implant-based breast reconstruction. The difference in sensation is most pronounced in the first 2 years postoperatively and at more than 4 years postoperatively. Further prospective studies are warranted to elucidate the exact sensory recovery trajectory in both the postoperative short term and long run.

PURPOSE: Tissue expander-based breast reconstruction is associated with high incidences of infectious and ischemic complications. Tissue expander characteristics, such as fill medium and volume, may influence risk of post-operative complications given their implications for the pressure exerted on mastectomy skin flaps. Our aim was to evaluate the influence of initial fill medium (air versus saline) on complications in immediate breast reconstruction within a propensity score-matched cohort.

METHODS: In this IRB-approved retrospective study, patients undergoing immediate tissue expander-based breast reconstruction with initial intra-operative fill with air were propensity score matched 1:2 to those with an initial fill of saline based on patient and tissue expander characteristics. The primary outcome of interest was the incidence of post-operative tissue expander-related complications, including mastectomy skin flap necrosis, based on the type of initial tissue expander fill (air versus saline). Secondary outcomes included predictors of ischemic complications across all studied variables, as determined by multivariate logistic regression.

RESULTS: A total of 584 patients were included in the study. Of these patients, 130 (22.2%) had initial tissue expander fill with air, 377 (64.6%) had initial fill with saline, and 77 (13.2%) had 0 cc of initial fill. After multivariate adjustment, higher intra-operative fill volume was the only variable associated with increased risk of mastectomy skin flap necrosis [Regression Coefficient (RC) 14.3; p=0.049]. Initial fill with air was not associated with risk of skin necrosis (RC 0.68; p=0.29). Propensity-score matching was then conducted among 360 patients (Air: 120 patients, Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p>0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p=0.003), seroma (p=0.004), and nipple necrosis (p=0.03).

CONCLUSIONS: In a propensity score-matched cohort, initial tissue expander fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. High initial intra-operative fill volume was independently associated with risk of mastectomy skin flap necrosis. Initial fill with air and lower intra-operative fill volumes may be strategies to reduce risk of ischemic complications among high-risk patients.

Purpose: Mantle field radiation was traditionally used to treat Hodgkin's lymphoma. These patients may require future mastectomy for breast cancer, in part due to the increased risk of breast cancer after mantle radiation and/or genetic mutations. We describe outcomes after mastectomy and immediate breast reconstruction (IBR) for patients with prior mantle radiation or prior whole breast irradiation (WBI).

Methods: A retrospective review of patients with prior radiation undergoing mastectomy and IBR from 2010-2020 was performed. Two groups were identified: prior mantle radiation and prior WBI. Demographics, co-morbidities, mastectomy and reconstruction details, and post-operative complications were recorded. Major complications were defined as requiring debridement in clinic, intravenous antibiotics, or re-operation.

Results: We identified 13 patients (25 breasts) with prior mantle radiation and 86 patients with unilateral WBI; all underwent subsequent mastectomy with IBR. Within the mantle cohort median age was 42.9 (IQR: 40.1, 48.7) and BMI was 23.7 (IQR: 21.7, 24.9). These were significantly lower than the prior WBI group, with a median age of 58.0 (IQR: 50.1, 63.9, P < .001 ) and BMI of 26.6 (IQR: 23.9, 30.2, P = .016).

Within the mantle radiation cohort, nipple-sparing mastectomy (19 breasts, 76%) with tissue expander/implant reconstruction (21 breasts, 84%) was the most common approach. Average tissue expander fill was 348 cc (SD: 127 cc), and average implant size was 430 cc (SD: 84 cc). The only autologous reconstruction performed was one patient who underwent bilateral deep inferior epigastric flaps. Fat grafting at the final stage of reconstruction (76%) and use of acellular dermal matrices at some point in reconstruction (84%) were both common. None in the mantle cohort underwent re-radiation. Nipple-sparing mastectomy was more frequent within the mantle group compared to the WBI group (36 breasts, 42%, P = .018). Otherwise, no significant differences were seen in reconstruction characteristics.

Major complications were observed in 2 breasts with prior mantle radiation (8%) and 18 breasts with prior WBI (21%) (P = .235). The mantle major complications were both flap necrosis debrided in the operating room, and neither required conversion to another type of reconstruction. In the prior WBI group, two major complications required conversion to autologous reconstruction and five failed reconstruction requiring flat closure.

On univariate analysis of the combined cohorts, higher BMI was the only factor associated with higher risk of major complications (OR 1.54, 95% CI 1.005-2.41, P = .047). There was no significant difference in major complications between the prior mantle and prior WBI groups on univariate analysis (OR 0.33, 95% CI 0.05-1.26, P = .1553). Higher BMI was no longer a significant risk factor on multivariate analysis (OR 1.44, CI 0.92-2.28, P = .11).

Conclusion: Although a sizeable minority of patients experience major complications, our findings suggest that IBR may be feasible in select patients after previous mantle field radiation or WBI.

Background: Deep inferior epigastric perforator (DIEP) flap reconstruction may occur immediately after mastectomy procedures or be delayed and performed during a separate operation. This study sought to differentiate population characteristics of patients who undergo immediate versus delayed DIEP flap breast reconstruction and assess the safety profiles of these surgeries. Methods: This retrospective study included patients who underwent DIEP breast reconstruction between January 2016 and July 2022 at a tertiary-care, academic institution. Demographics and outcomes were compared using two-sample t-test or Chi-square analysis. Results: Of the 669 patients included, 274 (41.0%) patients received immediate and 395 (59.0%) received delayed DIEP flap breast reconstruction. Overall, median age was 51 (IQR: 45, 58) years old and median BMI was 29.0 (IQR: 25.8, 32.3). Age, BMI, history of diabetes or tobacco use, intraoperative complications, readmission and reoperation rate were not significantly different between cohorts. However, immediate DIEP flap breast reconstructions had higher rates of overall postoperative complications (18% vs 12%, p=0.029) driven by higher rates of hematoma formation (4.4% vs 1.8%, p<0.001) compared to delayed DIEP flap breast reconstruction. Conclusions: Immediate DIEP flap breast reconstruction was associated with higher rates of postoperative complications. Although breast reconstruction at time of mastectomy offers reduced cost, shorter overall recovery time, and fewer events requiring general anesthesia for patients, our findings contribute to evaluation of surgical candidacy for immediate versus delayed DIEP breast reconstruction.

Introduction: Breast implant associated biofilm formation leads to postoperative complications like infections, re-operations, and possibly malignancy. Biofilms are difficult to treat given the resultant matrix often being impenetrable to antimicrobial agents and limited intrinsic blood flow to the implant. There is no consensus among surgeons regarding the best protocol for preventing breast implant associated biofilm, and no high quality systematic reviews in the last 5 years to our knowledge. The purpose of this study was to review current literature related to breast implants and biofilms given the popularity of this topic in recent literature.

Method: A systematic review was performed per PRISMA guidelines. PubMed was queried for records from 1/2015 to 7/2022 related to biofilms and breast implants. Excluded articles included: ones that did not address biofilms in the context of breast implants, single case reports, reviews, replies, or commentaries.

Results: Of the 83 available articles, 51 met the inclusion criteria. The overarching themes included mechanism of biofilm formation, intraoperative prophylactic methods against biofilms, role of implant type of biofilm formation, and the relationship between biofilms and malignancy. S. aureus and S. epidermidis were identified as the most common causative agents of persistent infections in breast implants. Survey studies revealed chlorhexidine to be the most common skin antiseptic, with one in vitro study finding it to be more effective in preventing capsular contracture than povidone-iodine. However, povidone-iodine was identified in several studies as an effective breast pocket irrigation in reducing bacterial contamination and capsular contracture. Plasma activation was also identified as an effective inhibitor of bacterial growth when combined with antibacterial irrigants. Several studies conflicted on whether hypochlorous acid containing irrigants were superior to povidone-iodine. Many in vitro studies identified greater biofilm loads on textured implants, contrasting with studies identifying breast implant texture as protective against capsular contracture as many studies identified biofilms as a likely contributor to capsular contracture through chronic inflammation. One prospective study using patient data found no relationship between implant texture and breast implant illness. The "no-touch" technique when inserting an implant was robustly present in the literature as a mechanism of infection prophylaxis. For two-stage implant-based reconstruction, delaying expander inflation until 6 weeks postoperatively was shown to decrease biofilm formation. Novel capsular contraction treatment shown to be effective included capsulectomy followed by antibiotic-impregnated mesh or even open capsulotomy over capsulectomy. Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was also discussed at large in these studies and remains a key area of study in plastic surgery. Basic science and retrospective clinical studies pointed to a possible infectious contributing cause to BIA-ALCL development.

Conclusion: Recent contributions to the literature about biofilms and breast implant revolve around mechanism of biofilm formation, intraoperative prophylactic methods against biofilms, role of implant type of biofilm formation, and the relationship between biofilms and malignancy. Conflicting theories remain regarding the relationship between implant texture, ALCL, biofilm formation, and capsular contracture. Further research is needed to better elucidate these concepts and inform recommendations to prioritize patient safety.