Scientific Abstract Presentations: Top Residents Abstract Session 2 (Breast Reconstruction) Friday, October 27 Fri, Oct 27 8:00-9:00 a.m. CDT

Background: Assessment of breast volume is essential in preoperative planning of immediate breast reconstruction (IBR) surgery in order to achieve a satisfactory cosmetic outcome. This study introduced a breast volume measurement tool that can perform segmentation of magnetic resonance images (MRI) and calculate breast volume automatically. We compared the accuracy and reliability of this measurement method with four other conventional modalities.

Methods: Patients scheduled to undergo mastectomy with IBR between 2016 and 2021 were enrolled in the study. Five different breast volume assessments, including automatic segmentation of MRI, manual segmentation of MRI,¹ 3D surface imaging,² mammography,³ and the BREAST-V formula,⁴ were used to evaluate different breast volumes. The results were validated using water displacement volumes of the mastectomy specimens.⁵

Results: Breast volumes measured by automatic and manual segmentation of MRI had lower mean relative errors (30.3%+/-22.0 (p=0.002) and 28.9%+/-19.8 (p=0.001), respectively) than 3D surface imaging (38.9%+/-31.2), Breast-V formula (44.8%+/-25.8) and mammography (60.3%+/-37.6%). There was a strong linear association between the MRI methods and the water displacement methods (automatic segmentation: r=0.911, p<0.001; manual segmentation: r=0.924, p<0.001), followed by 3D surfacing imaging (r=0.858, p<0.001), mammography (r=0.841, p<0.001), and the Breast-V formula method (r=0.838, p<0.001).

Conclusion: Breast volume assessment using the MRI methods had better accuracy and reliability than the other methods in our study. Breast volume measurement using automatic segmentation of MRI could be more efficient.

Reference Citations: 1. Howes BH, Watson DI, Fosh B, Yip JM, Kleinig P, Dean NR. Magnetic Resonance Imaging Versus 3-Dimensional Laser Scanning for Breast Volume Assessment After Breast Reconstruction. Ann Plast Surg. Apr 2017;78(4):455-459. doi:10.1097/SAP.0000000000000890 2. Eder M, Waldenfels FV, Swobodnik A, et al. Objective breast symmetry evaluation using 3-D surface imaging. Breast. Apr 2012;21(2):152-8. doi:10.1016/j.breast.2011.07.016 3. Fung JT, Chan SW, Chiu AN, Cheung PS, Lam SH. Mammographic determination of breast volume by elliptical cone estimation. World J Surg. Jul 2010;34(7):1442-5. doi:10.1007/s00268-009-0283-0 4. Longo B, Farcomeni A, Ferri G, Campanale A, Sorotos M, Santanelli F. The BREAST-V: a unifying predictive formula for volume assessment in small, medium, and large breasts. Plast Reconstr Surg. Jul 2013;132(1):1e-7e. doi:10.1097/PRS.0b013e318290f6bd 5. Yip JM, Mouratova N, Jeffery RM, Veitch DE, Woodman RJ, Dean NR. Accurate assessment of breast volume: a study comparing the volumetric gold standard (direct water displacement measurement of mastectomy specimen) with a 3D laser scanning technique. Ann Plast Surg. Feb 2012;68(2):135-41. doi:10.1097/SAP.0b013e31820ebdd0

Background: While autologous breast reconstruction offers unique advantages to implant based reconstruction, patients often experience higher rates of pain and longer recovery times. Regional blocks have since become a standard of care in enhanced recovery after surgery (ERAS) protocols, with literature demonstrating improved pain management, decreased opioid use, and decreased length of stay. Although the transversus abdominis plane (TAP) block is the most widely used regional block in autologous breast reconstruction, there is limited data comparing the efficacy of different block types in breast surgery. Our institution has since implemented a Quality Improvement study to determine if an anterior quadratum lumborum block (aQLB) could provide superior outcomes to the traditional TAP block, as part of our breast reconstruction ERAS pathway.

Methods: A total of 170 patients were enrolled in this quality improvement study. 72/170 patients received an intra-operative, bilateral TAP block by the operating surgeon using bupivacaine plus liposomal bupivacaine. 98/170 patients received a preoperative, bilateral aQLB by an anesthesiologist using bupivacaine plus dexamethasone and methylprednisolone acetate. All patients underwent breast reconstruction with autologous DIEP flaps (72/170 unilateral and 98/170 bilateral). Reconstruction was either immediate (unilateral n = 49, bilateral n = 69) or delayed (unilateral n=23, bilateral n= 29) following mastectomy. Outcomes measured included patient demographics, average pain scores, average daily opioid consumption, length of PACU stay, length of hospital stay, and post-operative venous thromboembolism (VTE) or pulmonary embolism (PE). Average values with standard deviation were calculated using t-test and median data with interquartile ranges were calculated using non-parametric Wilcoxon rank sum test.

Result: Preoperative aQLB in our ERAS pathway demonstrated a significantly lower post-operative daily milligram morphine (MME) consumption when compared to intra-operative TAP blocks (Median (IQR) 23.4mg (7.4mg, 42.0mg) to 9.7mg (3.8mg, 19.4mg), p<0.001). This data maintained statistical significance across all subvariant analyses, except in patients who underwent delayed unilateral reconstruction, which demonstrated a non-statistically significant lower MME in the aQLB group. Average daily pain scores, PACU length of stay, and hospital length of stay were not statistically different between regional blocks.

Conclusion: Pre-operative aQLB is an effective alternative to the conventional surgeon placed TAP block as an opioid-reducing pain control modality for DIEP flap breast reconstruction. Average hospital and PACU length of stay, subjective pain scores, and post-operative complication rates were found to be non-inferior for the aQLB when compared to TAP blocks.

Background: Many women undergoing mastectomy feel too overwhelmed to understand the deluge of breast reconstruction information provided to them. Lower patient satisfaction with the information provided before reconstruction results in increased decision regret and decreased satisfaction with the outcome of their reconstructive surgery. Most reconstructive surgeons rely on a combination of hand‐drawn diagrams, brochures, and perioperative photos of other patients to share information during the reconstruction consultation process. This has led to low rate of retention and recall, as it is difficult for many patients to conceptualize and visualize complex breast reconstruction procedures. Three‐dimensional (3D) interactive technology has been shown to be a valuable tool in enhancing patient education. Knowing these benefits, we developed a prototype of an interactive 3D decision support tool for women. We conducted a pilot study to assess the feasibility of implementation of this decision support tool during breast reconstruction consultation. Methods: Women > 18 years of age presenting for breast reconstruction consultation were eligible. Patients were randomized into an experimental (3D decision support tool and standard of care) or control group (standard of care alone). Patient-reported outcome measures completed for this study include BREAST-Q satisfaction with information and satisfaction with breasts, decision regret scale, and decision quality index for knowledge about reconstruction, goals and concerns, and involvement in decision making. These were completed at various timepoints including before consultation, immediately after consultation and at 4-weeks and 3-months postoperatively(PO). Results: Sixty-four patients were evaluable for the study endpoints (31 experimental, 33 control). 84% of patients underwent implant-based reconstruction (n = 54). There were no significant findings between the experimental and control groups throughout respective timepoints. Mean satisfaction with information scores were similar in the experimental group (mean 54, 95% CI 52, 56) and control group (mean 52.9, 95% CI 50, 56) at 4 weeks, and 3-months PO. In the experimental group, mean knowledge scores increased significantly from baseline (mean 60, 95% CI 52, 68) to post-consultation (mean 69, 95% CI 63, 76; p=0.03); a significant increase in knowledge was not observed for the control group at these time points (p=0.19). Mean satisfaction with breast scores in the experimental group were significantly lower at 4 weeks (mean 37, 95% CI 32, 43) PO compared to 3 months (mean 46, 95% CI 43, 49 p=0.007) PO. A similar increase for satisfaction with breasts was observed in the control group (4 week mean 35, 95% CI 28, 41 vs. 3 months mean 42, 95% CI 37,47, p=0.013). Finally, there was a significant decrease in decision regret for the experimental group from after consultation (mean 20, 95% CI 14, 26) to 4-weeks (mean 10, 95% CI 3.7, 16; p=0.007) and 3-months (mean 11, 95% CI 5.3, 16; p=0.01), which was not seen in the control group at 4-weeks (p=0.31) and 3-months (p=0.9) postop. Conclusion: Incorporating a 3D decision support tool for breast reconstruction during consultation with a reconstructive surgeon is feasible. patients in the 3D education group reported less decision regret and saw improvements in reported knowledge over time, changes that were not noticed in within the control group. Future work will include an appropriately powered randomized control trial to further define the impact of an interactive decision support tool for post mastectomy reconstruction.

Abstract Title: Delayed Mastopexy with Fat Grafting and Implant Pocket Revision (DM-IPR) Following Nipple Sparing Mastectomy (NSM)

Authors: Daisy Sanchez, MD, Maxine Garcia, MD, Lucia Castro, MD, Jennifer Comptis, MD, Yoav Barnavon, MD FACS

Goals/Introduction: Many patients have ptosis but still would like to undergo nipple sparing mastectomy (NSM). Mastopexy done concurrently with mastectomy can be hazardous. Several strategies have been developed to reduce the likelihood of nipple-areolar (NAC) necrosis in this cohort of patients. Delayed mastopexy with implant pocket revision (DM-IPR) is one such alternative.

Methods: In order to evaluate the outcomes of patients undergoing DM-IPR, we retrospectively reviewed our records from 2015 to 2021. We identified patients with ptosis who underwent NSM and immediate reconstruction with expander or implant. IPR was undertaken with popcorn capsulorrhaphy, posterior capsular flaps and the use of poly-4-hydroxybutyrate (P4HB) mesh. The inclusion criteria included those patients who subsequently underwent DM-IPR. Patients' charts were reviewed for pre-operative demographic data, operative notes, post-operative progress notes and photographs.

Results: 13 patients (23 breasts) met the inclusion criteria. Of those, 4 underwent direct to implant (DTI) pre-pectoral reconstruction, 4 underwent DTI sub-pectoral reconstruction and 5 underwent expander placement following NSM. Patients had a second stage reconstruction which included implant pocket revision, mastopexy with NAC transposition on a wide dermal pedicle and simultaneous fat grafting. One patient had a complication of persistent implant flipping requiring secondary implant pocket revision. All patients had satisfactory outcomes.

Conclusion: Delayed mastopexy with fat grafting and implant pocket revision is a safe and reproducible strategy to achieve satisfactory breast reconstructions in patients with ptotic breasts. None of the patients in this series had NAC necrosis. All had successful reconstructions.

Purpose Oncoplastic breast-conserving surgery (BCS) is an effective approach for the treatment of small breast cancer. However, achieving a natural breast contour can be challenging in Asian women, who tend to have smaller breast volume but relatively larger tumors [1]. There have been studies that tried volume replacement using only diced acellular dermal matrix (ADM) [2]. In our experience, pieces of diced-ADM were sometimes touched elsewhere, so we tried sealing the defect with a sheet-ADM so that the diced-ADM stays in place. It is possible to implement a natural breast contour without bulging or depression deformity. The aim of this study is to compare aesthetic outcomes and complications between diced-ADM alone and the additional use of a sheet-ADM.

Methods We performed a retrospective analysis of patients who underwent oncoplastic BCS from June 2020 to June 2022. Diced-MegaDerm^® (L&C Bio, Seoul, Korea) and 1.8 mm thick and 3x4 cm^2 in size BellaCell-HD^® (Hans Biomed, Seoul, Korea) were used to fill the defect. First, the resected breast tissue was weighed and the required volume of ADM was determined. The Jackson–Pratt drain was inserted and diced-ADM was filled to the defect. It was covered with a sheet-ADM, and the remaining glandular tissue and a sheet-ADM were sutured. The patient's baseline characteristics and operative data were analyzed. Satisfaction and aesthetic outcomes were assessed using the BREAST-Q survey and Validated Breast Aesthetic Scale.

Results A total of 168 patients were enrolled in this study. 53 in the diced-ADM and a sheet-ADM group and 115 in the diced-ADM only group. The mean weight of resected breast tissue was 18.1 g with sheet-ADM and 17.3 g without, and the mean volume of used diced-ADM was 18.6 g with sheet-ADM and 17.7 g without. None of the complications were statistically significant in either group: seroma was 9.4% with sheet-ADM and 9.7% without, red breast syndrome was 1.9% and 4.3%, hematoma was not observed in either group, and infection was 0% and 2.7%. Among the aesthetic problems, depression deformity was 1.9% in sheet-ADM and 5.2% without, and bulging deformity was 0% and 2.7%, respectively, which were not statistically significant. However, the hardness sensation was not observed with sheet-ADM but was identified 8.7% inthe without group, which was statistically significant (p=0.032). In aesthetic outcomes, mean BREAST-Q scores were higher in sheet-ADM, 85.7 and 82.4 in the two groups respectively, which was statistically significant (p=0.031). The Validated Breast Aesthetic Scale was also higher in sheet-ADM, but not statistically significant.

Conclusion The combination of diced and sheet ADM avoids the disadvantages of using diced ADM alone, such as uneven surface texture and small ADM pieces falling into the space between the glandular flap and the pectoralis major muscle [2, 3]. The aesthetic results of using both diced and sheet ADM were statistically better than using diced ADM alone, while the incidence of complications was similar between the two groups. Our results suggest that this technique may be a useful tool for plastic surgeons to achieve excellent aesthetic results in oncoplastic BCS.

References 1.Yang JD, Lee JW, KimWW, JungJH, Park HY. Oncoplastic Surgical Techniques for Personalized Breast ConservingSurgery in Breast Cancer Patient with Small to Moderate Sized Breast. J. Breast Cancer. 2011;14:253–61. 2. Gwak HK, Jeon YW, Lim ST, Park SY, Suh YJ. Volume replacement with diced acellular dermal matrix in oncoplastic breast-conserving surgery: a prospective single-center experience. World J Surg Oncol. 2020;18:60. 3. An JS, Kwon HJ, Lim WS, Moon BI, Paik NS. The Comparison of Breast Reconstruction Using Two Types ofAcellular Dermal Matrix after Breast-Conserving Surgery. J Clin Med. 2021;10:3430.

Purpose: Reported rates of infection following implant-based breast reconstruction (IBBR) range from 1-35% in the current literature. Despite this relatively high rate, there is no consensus regarding optimal practices for IBBR such as the type or duration of antibiotic prophylaxis, which has led to a wide variety of adopted protocol among plastic surgeon practice. Quality improvement (QI) projects have long standing evidence of efficacy in surgery, however, only a handful of previous QI projects have been documented that specifically target the reduction of complications after breast reconstruction. The purpose of this study is to present the short-term outcomes from the early stages of the MIAMI protocol (Minimizing Infection After Mastectomy with Implants), a self-manufactured QI project to standardize preoperative, intraoperative, and postoperative breast reconstruction protocol at our institution.

Methods: The MIAMI protocol was instituted on December 1, 2022, at both the University of Miami and Jackson Memorial Hospital Systems. Incidence of five complications (infection, wounds, hematoma, seroma, flap necrosis) in addition to reoperation for a complication and implant loss following IBBR were evaluated for six faculty members and compared between a period before the start of the protocol (01/01/2022-11/30/2022) and after (12/01/2022-02/05/2023). Protocol including standardization in the preoperative area, during surgery and postoperative (Table1) Standardization did not include post discharge antibiotic type or duration.

Results: Four-hundred and twenty IBBR procedures were included in total, 360 (86%) of which were performed prior to the start of the MIAMI protocol and the remaining 60 procedures (14%) performed once the protocol were in place. Average patient age throughout the study period was 51 years and body mass index 27.3 kg/m2. Overall infection rate was 14.5%. IBBR procedures performed after the start of the protocol were found to have significantly fewer incidences of infection (16% vs 5%; p<0.0238), wounds or dehiscence (24% vs 7%; p<0.0022), and seroma (14% vs 0%; p<0.005) compared to before the protocol were in place. Though nonsignificant, rate of reoperation decreased from 14.7% to 8.3% after protocol implementation (p=0.1842), while operative implant removal declined from 13.3% to 8.3% (p=0.2802). The most common cause for reoperation both prior to (n=35, 66%) and following the MIAMI protocol (n=4, 80%) was infection, either with (n=9) or without (n=30) concurrent wound dehiscence or mastectomy flap necrosis.

Conclusion: Standardization of preoperative, intraoperative, and postoperative procedures for breast reconstruction had a significant impact on short-term surgical outcomes at our instruction, regardless of no consistent standardization for post discharge antibiotics. Rates of reoperation and operative implant removal declined, while significant decreases were noted for the incidence of infection, wounds or dehiscence, and seroma formation. The authors will continue to evaluate outcomes for these patients up to one postoperative year to determine the long-term efficacy and viability of the protocol.

Background: Breast cancer-related lymphedema results in chronic limb swelling with subcutaneous deposition of fluid, adipose, and fibrosis. Suction-assisted lipectomy commonly is performed as an excisional therapy to treat lymphedema. Patients who have had breast reconstruction after breast cancer often benefit from fat grafting. The purpose of this study is to introduce a novel concept for breast fat grafting from lipoaspirate in patients with breast cancer-related lymphedema.

Methods: A single-center retrospective review was performed on breast cancer patients with breast cancer-related upper extremity lymphedema who underwent liposuction as excisional treatment. Demographic data, diabetes, body mass index (BMI), smoking, length of lymphedema, performance of breast fat grafting, type of breast cancer resection, and details of reconstruction were analyzed. Outcome variables included improvement subjectively of the arm or breast, post-operative arm measurements, and complications.

Results: In our study period, 10 patients underwent arm liposuction of breast cancer-related lymphedema from 2019 to 2022. The average length of lymphedema diagnosis was 6 years. Six patients had a history of diabetes, hypertension, or smoking. The mean BMI was 37.2 kg/m2. All patients received a preoperative lymphoscintigram. Two patients underwent breast fat grafting with lymphedema lipoaspirate. The average amount of lymphedema lipoaspirate was 1.4 L. All patients had improvement subjectively of the affected arm. Of the two patients who underwent breast fat grafting, one patient had 40 mL of fat grafting to the affected breast. The other patient had a total of 270 mL of fat grafting to bilateral breasts (200 mL to the affected breast and 70 mL to the contralateral breast). Both fat grafted patients had subjective improvement of the affected arm and breast. One patient, who did not undergo fat grafting, had postoperative arm cellulitis.

Conclusion: Patients with breast cancer-related lymphedema who undergo liposuction may benefit from breast fat grafting. The lymphedematous arm may serve as a donor site for a large amount of adipose that can be used to therapeutically treat lymphedema and procure fat graft simultaneously.

Amyloidosis is characterized by extracellular deposition of insoluble misfolded beta-pleated proteins. Amyloid disease involving the breast is rare and there is a paucity of literature guiding surgical management in caring for these patients. The purpose of this article is to outline the algorithm used at our institution for breast reconstruction in patients diagnosed with amyloid disease involving the breast. In this case series, we present 5 cases of breast amyloidosis treated at the Medical College of Wisconsin between 2011 and 2021. The series includes 5 women with a median age of 70 years and a median follow up of 19 months (range, 9-80 months). All patients were diagnosed with light chain (AL) type of amyloidosis. Systemic amyloidosis was identified in 3 patients and localized disease was identified in 2 patients. Concurrent breast malignancy was identified in 2 patients who underwent skin-sparing mastectomies followed by breast reconstruction with both prosthetic and autologous techniques. Both prosthetic and autologous reconstructive techniques are safe in patients with amyloidosis however careful consideration and preoperative work-up are warranted to avoid complications in this vulnerable population. Further studies are warranted to improve surgical outcomes in patients with amyloidosis involving the breast.

Introduction/Goals:

Autologous breast reconstruction following nipple sparing mastectomy (NSM) is associated with greater patient satisfaction and quality of life outcomes when compared to implant-based reconstructions.1 The muscle sparing latissimus dorsi (MSLD) myocutaneous flap is a readily available option for autologous reconstruction despite concerns over its ability to provide enough volume for adequate reconstruction. We hypothesized that the MSLD flap with fat-grafting alone adds a substantial amount of volume that is retained over time and provides highly satisfactory clinical outcomes that are comparable to breast reconstructions performed with implants added to MSLD flaps.

Methods:

We retrospectively reviewed our database of patients who underwent MSLD flap breast reconstruction between March 2008 and February 2023. We identified all patients who had MSLD flap breast reconstruction with and without implant placement and/or fat-grafting. Patients were stratified into two groups: 1) autologous only (AO) reconstruction with MSLD flap and subsequent fat-grafting, and 2) implant-added (IA) reconstruction using MSLD flap with and without fat-grafting. Demographic information was collected including age, body mass index (BMI), smoking status, past medical and surgical history, and type of reconstructive procedure (immediate, delayed, or salvage). Clinical outcomes were evaluated by pre- and post-operative photographs, complications, and total number of fat-grafting events. Demographic data between groups were evaluated with a t-test. Chi-square tests of independence were performed comparing post-operative complications between groups. A p-value < 0.05 was considered significant.

Results:

There were a total number of 180 patients in the AO group and 36 patients in the IA group. While there was no significant difference in age between groups (p = 0.30), the average BMI of 29.37 kg/m2 in the AO group was significantly higher than the average BMI of 25.56 kg/m2 in the IA group (p < 0.001). The IA group had a greater proportion of salvage type procedures (52.78%) than the AO group (33.89%). The average number of total fat-grafting events per patient was 1.78 ([1-6 events per patient]) in the AO group and 1.56 ([1-5 events per patient]) in the IA group. While there was no significant difference in the overall complication rate between groups (p = 0.19), there was a significantly higher rate of infection in the IA group when compared to AO reconstructions (25% v. 11.67%, respectively; p < 0.05).

Conclusion:

The MSLD myocutaneous flap with subsequent fat-grafting alone provides patients with the benefits of an autologous reconstruction, breast volume preservation, and a decreased risk of post-operative infection. On the other hand, implant-added breast reconstruction with MSLD myocutaneous flaps may have added utility in patients with lower BMIs and salvage type procedures. Overall, AO and IA breast reconstructions utilizing MSLD myocutaneous flaps and subsequent fat-grafting are both safe and reliable approaches for patients following NSM.

Citations: 1. Santosa KB, Qi J, Kim HM, et al.. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. 2018;153:891–899.

Background: An important component of preoperative counseling and patient selection involves surgical risk- stratification. There are many tools developed to predict surgical complications. The Modified Fragility Index (mFI) calculates risk based on the following five elements: hypertension, COPD, CHF, DM and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR).

Methods: A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 were queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications.

Results: 547 patients were included in the study cohort. The average age was 55 and the average BMI was 33.5. The overall complication rate was 19% (n=105) and the major complication rate was 9% (n=49). Higher fragility scores were significantly associated with the development of major complications (p=0.028). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, BMI and resection weights were not associated with complications (p=0.15, p=0.87 and p= 0.30 respectively).

Conclusion: The mFI predicts surgical risk in patient who are undergoing oncoplastic reduction. Benefits of this risk assessment tool include its ease of calculation. Our study is the first to demonstrate its utility in OCR.