Scientific Abstract Presentations: Breast 4 Friday, October 27 Fri, Oct 27 10:30 a.m.-12:30 p.m. CDT

Introduction:
Nipple-sparing mastectomy (NSM) is aesthetically superior to skin-sparing only mastectomy or reconstructed nipples. However, NSM partially preserves nipple ducts which are remaining communications between the environment and breast pocket that can potentially allow bacteria transfer and compromise the prosthesis, particularly if in a pre-pectoral position. Frequently used acellular dermal matrix (ADM) or external nipple adhesives may serve as subareolar "barriers" to reduce through-duct bacteria penetration but can serve as costly and/or temporary solutions. We propose: SAS-Subareolar Sealant. SAS involves the application of a synthetic sealant on the nipple undersurface prior to implant placement as the sole or adjunctive protection from nipple-derived contamination.

Methods:
All patients undergoing immediate breast reconstruction with pre-pectoral implants (tissue expanders or permanent implants) after NSM by the senior author between April 2013 to January 2021, were included in this study. Cohorts were stratified into breasts that received SAS and No-SAS. SAS first involves application of a synthetic sealant to the undersurface of spared nipples after mastectomy. Subsequently, ADM was anchored to the mastectomy flap covering the undersurface of the nipple and incision line.

Complications that occurred within 30 days were analyzed using a Generalized Estimating Equation (GEE) logistic regression model to account for repeating patient sides (e.g., breasts). Minor complications included "at least one minor complication," erythema, extra-antibiotics, flap necrosis, nipple necrosis, and seroma. Major complications involved "at least one major complication," such as capsular contracture, dehiscence, infection, hospitalization, implant loss, necrosis requiring surgery, and surgery for any complications.

Results:
The study investigated 77 breasts that received prepectoral prosthetic breast reconstruction. SAS was applied in 70 of 77 breasts. We found that No-SAS was 10.4-fold more likely to result in infection (p = 0.032) and 17.3-fold more likely to require post-operative re-hospitalization (p = 0.018). No-SAS also resulted in significantly more 'at least one minor complication' (p < 0.001), erythema (p < 0.001), capsular contracture (p = 0.033), and necrosis requiring surgical debridement (p < 0.001). However, No-SAS was associated with less rates of dehiscence than SAS (p < 0.001). After analyzing the initial outcomes, the No-ASA approach was discontinued to favor SAS technique.

Conclusion:
SAS results in lower infection and post-operative hospitalization rates, and reduces minor complications, such as erythema. SAS also reduced major complications, such the need for an additional surgery and capsular contracture. We believe that SAS provides an internal barrier against the environment and the flora residing within severed ducts, resulting in markedly reduced post-operative complications.

Purpose: Psychological factors may be associated with postoperative complications following breast reconstruction [1]. Despite significant research investigating surgical factors associated with postoperative outcomes, there is a paucity of data concerning patient-reported factors [2]. This study aimed to determine the association between preoperative BREAST-Q and postoperative complications after breast reconstruction surgery.

Methods: A mixed method, prospective-retrospective, study of 122 breast cancer patients undergoing breast reconstruction from January 2016 to May 2022 was approved at The Ottawa Hospital. All patients completed the BREAST-Q; patient demographics, surgical characteristics, and postoperative complications were recorded. The association of the preoperative BREAST-Q domain of patient-reported satisfaction and well-being and postoperative complications was analyzed using multivariable logistic regression. P values < 0.05 were considered statistically significant.

Results: On univariate analysis, patients who reported lower preoperative breast satisfaction with how they appeared in the mirror were significantly more likely to develop a major complication postoperatively (p=0.0122). There was no significant association between preoperative satisfaction scores and minor complications. On multivariable logistic regression analysis, after controlling for age, body mass index, and use of radiotherapy, patients who reported lower preoperative breast satisfaction had an increased risk for major wound complications requiring unplanned OR take-back (p=0.02477).

Conclusions: Lower patient-reported preoperative breast satisfaction was associated with an increased risk of major wound complications and unplanned OR take-back. Preoperative psychological and physical well-being factors were not predictors of major complications postoperatively. These findings support existing data that preoperative patient-reported body image satisfaction may predict surgical outcomes. Our study highlights preoperative breast satisfaction as a key preoperative target that may optimize breast reconstruction outcomes.

References: [1] Lewis, H. C., Hart, A. L., Fobare, A., Styblo, T. M., & Losken, A. (2022). Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction. Plastic and reconstructive surgery, 149(3), 568–577. https://doi.org/10.1097/PRS.0000000000008825 [2] Lewis‐Smith, H., Diedrichs, P. C., Rumsey, N., & Harcourt, D. (2018). Efficacy of psychosocial and physical activity‐based interventions to improve body image among women treated for breast cancer: A systematic review. Psycho-Oncology (Chichester, England), 27(12), 2687–2699. https://doi.org/10.1002/pon.4870

Background: Breastfeeding is known to have numerous physical as well as mental health benefits for both infant and mother. Conversely, the inability to breastfeed is associated with increased maternal anxiety and may play a role in post-partum depression.1 Any surgery to the breast can theoretically adversely affect future lactation either via mechanical disruption/resection of glandular tissue and ducts or pressure-related atrophy. Some publications have argued that certain breast surgeries do not significantly impair breastfeeding, but more recent literature has challenged these notions.2 Conversely, plastic surgeon preoperative counseling practices regarding lactation after breast surgery have not yet been studied. We surveyed members of ASPS to elucidate breastfeeding counseling practices among plastic surgeons in patients consulting about breast surgery.

Methods: A 25-question survey was distributed to 6,000 ASPS members from November 2021 to January 2022. It included questions on breastfeeding counseling practices, personal breastfeeding experiences, demographics, surgical training, and length in practice. Data analysis included descriptive statistics, independent t-tests, analysis of variance (ANOVA) tests, and Fisher Exact tests.

Results: 146 respondents were included. 90.7% of respondents believe that breast surgery can affect future lactation. While 96.6% of respondents routinely discuss possible postoperative challenges with breastfeeding, 39.3% differentiate between inclusive and exclusive breastfeeding, 22.2% discuss potential emotional consequences, and only 12.8% discuss the need for galactagogues or labor-intensive ancillary activities to induce lactation. When performing immediate reconstruction, 62.1% of respondents believe plastic surgeons are responsible to counsel on breastfeeding risk in case of lumpectomy and 33.6% in case of mastectomy. Only 64% of respondents reported breastfeeding impairment counseling prior to female-to-male top surgery. There was no difference in responses between respondent gender or personal/spouse history of breastfeeding. Those whose practice constituted >50% breast surgery rated a higher risk of lactation impairment with breast augmentation mastopexy using a subglandular (p=.020) or dual plane/submuscular implant (p=.005), and breast reduction (p=.015), compared to those with a <50% breast surgery practice. Significantly more respondents who had been in practice <15 years believed that breast surgery can affect lactation compared to those who had completed training ≥ 15 years ago (96% vs 84%, p= 0.05).

Conclusions Most plastic surgeons believe breast surgery can affect lactation and counsel patients as such. However, the potential deleterious mental health consequences of challenged lactation after breast surgery appears under-recognized and thus under-counseled. Plastic surgeons, especially those whose practice constitutes <50% breast surgery, may be underestimating the breastfeeding impairment risks. Prior to reconstruction post lumpectomy or mastectomy, many plastic surgeons rely on the oncological surgeon to counsel on breastfeeding impairment risk. Similarly, preoperative counseling in the top surgery population may be inadequate. Our findings highlight a potential need for increased education and improved preoperative breastfeeding counseling protocols for plastic surgeons.

References 1. Pope CJ, Mazmanian D. Breastfeeding and Postpartum Depression: An Overview and Methodological Recommendations for Future Research. Depress Res Treat. 2016;2016:4765310. doi:10.1155/2016/4765310 2. Kraut RY, Brown E, Korownyk C, et al. The impact of breast reduction surgery on breastfeeding: Systematic review of observational studies. PLoS One. 2017;12(10):e0186591. doi:10.1371/journal.pone.0186591

Purpose Pediatric gynecomastia is a common condition which causes significant psychosocial distress for the adolescent male. A wide variety of procedures have been described to treat gynecomastia, however, a paucity of literature exists regarding technique selection for adolescent gynecomastia especially in relation to the severity of deformity. This retrospective review aims to identify patient factors associated with surgical technique selection and establish an algorithm for the surgical management of pediatric gynecomastia.

Study Design A retrospective analysis was performed of all pediatric gynecomastia surgeries performed by a single surgeon from 2012-2022. Charts were analyzed for patient and operative demographics, endocrinologic comorbidities, complications, and outcomes. Data was analyzed using odds ratio and logistic regression analysis.

Results Forty-two surgically-managed gynecomastia patients under the age of 18 were identified for analysis. Patient average age at surgery was 16.3 years old with mean BMI of 27. Most patients were overweight or obese (54.8%) with Simon Grade III gynecomastia (35.7%). Endocrinologic assessment demonstrated the majority (81.0%) of patients had gynecomastia of idiopathic origin.

In regard to surgical management, four main surgical techniques were utilized: inferior periareolar mastectomy (IPM) (n=20, 47.6%), superior pedicled periareolar reduction (SPPR) (n=7, 16.7%), transverse mastectomy with free nipple grafting (TMFNG) (n=12, 28.6%) and transverse mastectomy with inferior pedicle (TMIP) (n=3, 7.1%).

IPM was primarily used for grade 1 and 2a patients with anatomically appropriate sternal notch to nipple (SNN) distances (mean 19.8cm). SPPR was utilized in grade 2a and 2b gynecomastia, also for patients with anatomically appropriate SNN distances (mean: 18.35cm). TMFNG was used for grade 3 deformities with mean SNN of 25.9cm. The few cases with TMIP were used in grade 2b and 3 deformities with mean SNN 26.2cm. Progression from IPM to SPPR and TMIP/TMFNG techniques was positively correlated with both increasing Simon grade and breast excision weight, respectively.

Odds ratio analysis revealed that obese patients (BMI >30) were statistically significantly more likely to require mastectomy with free nipple grafting (OR 19.5, p =.0005, 95% CI: 1.29-4.65) as were patients with Simon grade 2b or 3 gynecomastia (OR 62.3, p=0.0007, 95% CI: 3.64-104.41). Multivariate logistic regression further supported that SSN> 23.5cm, resection weight >180g, and Simon 3 grade gynecomastia were associated with free nipple grafting technique (p < 0.05).

Conclusion Pediatric gynecomastia is an increasingly common diagnosis with a wide array of surgical treatment modalities. We propose an algorithm to help guide the extent of skin excision and scarring required to achieve aesthetic results. More severe cases may benefit from techniques often reserved for the adult gynecomastia population, such as transverse mastectomy with free nipple grafting. However, alternatives such as periareolar skin reduction can be considered in patients with good skin quality and mild skin excess to limit the scarring and potential nipple hypopigmentation associated with the transverse mastectomy and free nipple graft technique.

A rare subset of rapid breast enlargement typically occurring close to menarche has appeared in case reports since 1669 using inconsistent nomenclature: virginal hypertrophy, virginal mammary hypertrophy, virginal breast hypertrophy, juvenile mammary hypertrophy, juvenile hypertrophy of the breast, virginal macromastia, juvenile gigantomastia, puberty-induced gigantomastia, and gigantomastia of puberty. This investigation aimed to review the current literature regarding this condition, specify the phenotype, and contribute two recent cases to clarify the presentation and management of this rare but potentially illuminating form of abnormal breast growth. A more appropriate name for this condition is also proposed to better reflect presentation and pathophysiology.

A literature review was performed by searching for the above terms in PubMed. Many case reports which describe "virginal breast hypertrophy" simply feature patients with prodigious breast growth that share few other features with a more severe condition that often goes by the same name. To distinguish the condition in focus, we established the following criteria: breasts grow rapidly over weeks to months, are disproportionate in size or distorted, and are accompanied by signs of skin compromise. For cases that fit these criteria, information was collected on timing of onset, growth patterns, exam findings, laboratory studies, associated conditions, imaging, histopathology, treatment, and outcomes. Two additional cases are presented, and a more appropriate name is proposed.

An age range of 8 to 16 years old is mentioned frequently in the literature, but our review revealed a range of 10 to 24 years old. Patients often experience 3-6 months of rapid enlargement followed by slowed, continued growth into adulthood. On exam, one or both breasts are enlarged, disproportionate, distorted in shape, and possibly erythematous. The skin envelope is tight with areas feeling firm or almost ballotable. Laboratory studies are almost always normal. Despite characteristic imaging findings, histopathology ultimately distinguishes this condition from fibroepithelial tumors and normal hypertrophy. Biopsies and surgical specimens commonly reveal epithelial, myoepithelial, and ductal proliferation along with ductal dilatation, PASH, and minimal adipose tissue. No formal treatment guidelines exist, but the literature features four options: watchful waiting, non-operative medical therapy (e.g., tamoxifen), surgery (e.g., reduction mammaplasty or mastectomy), or a combination of non-operative and surgical management. Neither reduction nor mastectomy prevent recurrence, and this is especially true for patients who have not completed puberty. Clinicians must counsel peri-pubertal patients that the condition often recurs following surgery, and adjuvant tamoxifen or a repeat procedure may be necessary. The risk profile differs from that of a typical reduction, and there must be frank acknowledgment of suboptimal shape/texture outcomes. Given the draconian growth regardless of ultimate size, a better term is Fulminant Mammogenesis (FM). This name removes charged language such as "virginal" that unnecessarily implicates sexual activity status.

As a term, FM is inclusive of all demographic backgrounds and specifies a non-malignant diagnosis of sudden, severe mammary development. Review of the literature and presentation of two additional patients clarifies the criteria for FM, aids in its management, and suggests that evincing its pathophysiology may be instrumental in understanding normal postnatal breast development.

Purpose: Congenital breast asymmetry has significant adverse psychosocial sequelae on young women. As patients mature, the discrepancy in breast asymmetry may increase leading to even greater adverse effects on social functioning and emotional well-being. Autologous and implant-based techniques have been reported for correcting such asymmetry after breast maturity, however, little literature exists on the use of 2-stage breast reconstruction with tissue expander (TE) placement prior to breast maturity. TE placement allows for serial tissue expansion of the affected breast as the contralateral unaffected breast develops. In this abstract, we describe use of tissue expanders to maintain breast symmetry during breast development, prior to definitive reconstruction after breast maturation.

Methods: This study analyzed patients with congenital breast asymmetry who completed 2-stage breast reconstruction at a single institution from January 2000 to November 2022. Patients' medical and demographic information, TE and implant surgical information, complications, and satisfaction were analyzed.

Results: Thirty-one patients, ranging in ages from 11 to 31 years old, completed 2-stage breast reconstruction for congenital breast asymmetry. Sixteen (51.6%) were diagnosed with Poland syndrome, 10 (32.3%) with tuberous breast deformity, 2 (6.5%) with congenital breast hypoplasia, 2 (6.5%) with pectus excavatum, and 1 (3.2%) with anterior thoracic hypoplasia. Twenty-nine patients (93.5%) had a unilateral condition, with the right breast (51.7%) being more commonly affected than the left breast (48.3%). The majority of patients had anatomic nipple position (N=29, 93.5%) and at least some portion of the pectoral muscle present (N=22, 71%). Tissue expanders were placed through an inframammary fold incision in 90.3% of the patients (N=28), and the most common TE size used ranged from 451-550 cc (N=12, 38.7%). TEs remained in place for a median 325 days (63-2400 days), had a median final fill of 520 cc, and remained in place after final fill to implant placement for a median 153 days (27-1602 days). Most patients received a breast implant ranging from 350-450 cc (N=12, 38.7%). During implant placement, 2 patients (6.5%) received ipsilateral fat grafting, 15 patients (48.4%) received contralateral mastopexy, and 5 patients (16.1%) had an ipsilateral latissimus dorsi flap harvested to reconstruct the chest wall and anterior axillary fold. Nineteen patients (61.3%) had initial clinic presentation at age <18, 14 patients (45.2%) had a TE placed at age <18, and 9 patients (29%) had a breast implant placed at age <18. Four patients (12.9%) experienced TE ruptures prior to implant placement, and 2 patients (6.5%) had an infection post-implant placement. After 2-stage reconstruction, 5 patients (16.1%) had persistent asymmetry requiring surgical intervention, and 29 patients (93.5%) reported satisfaction with their final reconstruction in a postoperative clinic visit with their surgeon.

Conclusion: This study demonstrates 2-stage breast reconstruction is a viable option for patients with congenital breast asymmetry who present prior to completion of breast maturity. This approach facilitates maintenance of breast symmetry during the process of breast maturation through performance of intermittent, serial tissue expansion. Patient satisfaction was high and complication rates were similar to those who undergo other forms of reconstruction for congenital breast asymmetry.

Background: The deep inferior epigastric perforator (DIEP) flap has emerged as the gold standard for breast reconstruction following mastectomy.1 The employment of microvascular techniques causes endothelial trauma activating coagulation paths increasing microthrombosis risk.2,3 Multiple pharmacological agents have been investigated for thrombosis prevention in the setting of DIEP flaps with one of these agents being acetylsalicylic acid, or aspirin. Current literature evaluating postoperative aspirin in DIEP flaps varies on the dosage, duration, timing, and respective patient outcomes.2-5 The challenge of antithrombotic therapy exists in creating a balance between thrombosis prophylaxis and adverse bleeding events. In this study, we aim to identify relationships between the administration of aspirin at varying dosages and durations and postoperative outcomes in patients undergoing DIEP free flap breast reconstruction. Methods: With IRB approval, a retrospective chart review of 508 patients (843 flaps) who underwent DIEP flap breast reconstruction from January 2019-March 2022 at Atrium Health was completed. Patient demographics, medical history, operative course, and postoperative complications were collected. Results: Patients were grouped by no aspirin, 81mg, or 325mg postoperative aspirin. The no aspirin group experienced no flap failures. There was no significant difference in flap failure incidence between the 81mg and 325mg groups (p=0.11). There was no significant difference in incidence of hematoma requiring return to OR when comparing the no aspirin group to patients taking 81mg or 325mg (p=0.09). Additionally, no difference was found in hematoma incidence for the 81mg versus 325mg group (p=0.97). Conclusion: No difference in hematomas requiring operative intervention or flap failures was found in regards to postoperative aspirin use. There was also no difference in hematoma incidence with 81mg compared to 325mg of aspirin.

References: 1. Costanzo, D., Klinger, M., Lisa, A., Maione, L., Battistini, A., & Vinci, V. (2020). The evolution of autologous breast reconstruction. Breast Journal, 26(11), 2223–2225. https://doi.org/10.1111/TBJ.14025 2. Tran, N. v., Buchel, E. W., & Convery, P. A. (2007). Microvascular complications of DIEP flaps. Plastic and Reconstructive Surgery, 119(5), 1397–1405. https://doi.org/10.1097/01.PRS.0000256045.71765.96 3. Enajat, M., Aziz Mohammadi, M., Debeij, J., van der Hulst, R. R. W. J., & Mureau, M. A. M. (2014). Effect of acetylsalicylic acid on microvascular thrombosis in autologous breast reconstruction. Journal of Reconstructive Microsurgery, 30(1), 65–70. https://doi.org/10.1055/S-0033-1356553/ID/JR130093-33 4. Knackstedt, R., Djohan, R., & Gatherwright, J. (2019). Thromboprophylaxis in breast microvascular reconstruction: a review of the literature. European Journal of Plastic Surgery, 42(4), 317–324. https://doi.org/10.1007/S00238-019-01510-4 5. Halle, M., Docherty Skogh, A. C., Friberg, A., & Edsander-Nord, Å. (2016). Breast free flap complications related to haematoma formation – do the risks of multiple antithrombotics outweigh the benefits today? Journal of Plastic Surgery and Hand Surgery, 50(4), 197–201. https://doi.org/10.3109/2000656X.2016.1151435

Purpose: Loss of breast sensation following mastectomy is a well-defined phenomenon. Sensory nerves exhibit slow and variable recovery; prior studies have identified that return to sensation is affected by mastectomy technique and reconstruction type, among other factors. However, chemotherapy and radiation have been less studied with respect to their impact on neural regeneration, both in autologous and alloplastic reconstruction.

Methods: Women undergoing mastectomies with immediate reconstruction via neurotized deep inferior epigastric perforator (DIEP) flaps or alloplastic reconstruction with tissue expanders were identified and followed prospectively. Neurosensory testing was performed in 9 breast regions using a pressure-specified sensory device to determine 1-point static cutaneous thresholds. Patients were stratified by preoperative or postoperative exposure to chemotherapy and/or radiation therapy, and Student's t-tests were performed between groups both preoperatively and at set intervals for three years following mastectomy to measure differences in sensation.

Results: 233 patients underwent neurosensory testing before or after mastectomy with reconstruction. Some patients underwent testing at multiple timepoints, accounting for a total of 770 measured breasts; 132 patients received DIEP flap reconstruction, and 101 patients received tissue expander-based reconstruction. Of the patients that received DIEP flap reconstruction, 31 did so in a delayed fashion, at a median of 12 months after mastectomy. 64 breasts were exposed to pre-mastectomy radiation therapy, and 178 to post-mastectomy radiation therapy. 174 breasts received pre-mastectomy chemotherapy, and 188 received post-mastectomy chemotherapy. Patients undergoing autologous reconstruction were more likely to receive postoperative chemotherapy; there were no other significant differences across groups regarding adjuvant treatment. Preoperatively, patients that received radiation therapy had significantly worse sensation before mastectomy (p<0.001), though this difference resolved by one year postoperatively. Conversely, patients that received postoperative radiation did have significantly worse sensation at one year postoperatively, regardless of reconstructive group (p<0.01). With regard to chemotherapy, there was no difference in preoperative sensation between groups exposed to preoperative chemotherapy. However, at one year postoperatively, patients that underwent either preoperative or postoperative chemotherapy had reduced sensation compared to their untreated counterparts (p<0.01). At three years after mastectomy, only the DIEP patients that received preoperative chemotherapy had reduced sensation; all other DIEP patients (postoperative chemotherapy, preoperative/postoperative radiation) and all tissue expander patients had no differences in sensation.

Conclusions: Breast sensation following mastectomy with autologous or alloplastic reconstruction is negatively influenced by radiation and chemotherapy. While the negative impact is noticeable at one year after mastectomy, it is mostly resolved by three years after, suggesting that chemotherapy and radiation slow down the speed of nerve recovery without affecting the overall recovery potential. Identifying these risk factors allows providers to better set expectations with patients when discussing reconstruction options. More follow-up must be done to understand the long-term implications of adjuvant cancer treatment on breast sensation.

Background Accurate diagnosis of peri-prosthetic infections following breast reconstruction is imperative to reduce morbidity. Alpha-defensin-1 (AD-1) is an antimicrobial peptide released by neutrophils that targets metabolically active microbes in the setting of ongoing infection. We previously demonstrated superior sensitivity and specificity of AD-1 in the identification of peri-prosthetic breast infection when compared to standard bacterial culture. This study evaluates the relationship between quantitative AD-1 levels and infection severity in patients with suspected peri-prosthetic infection. We hypothesize that levels of AD-1 within peri-implant fluid samples correlate with degree of infection. Methods A retrospective review of a prospective database was conducted of patients with prior breast implant reconstruction undergoing surgery for suspected infection between June 2018 and June 2019. Peri-prosthetic fluid was sampled, and AD-1 levels were sent for quantitative analysis. Each patient was assigned an infection severity, as previously described by Spear et al (2004). Analysis was conducted to evaluate odds of clinical outcomes and management, by breast, with increasing AD-1 levels. The correlation between AD-1 levels and systemic markers of infection was studied. Ordinal logistic regression was performed to evaluate the correlation between infection severity and AD-1 level. Results Twenty-nine patients met inclusion criteria (nine=bilateral breast surgery) resulting in a total of 38 breasts. Mean age was 56.7+/-13.9 years. Fifteen breasts (38.4%) were found to have peri-prosthetic infection diagnosed intraoperatively. Breasts found to be infected intraoperatively had significantly higher quantitative AD-1 levels (3.9 vs 0.14, p<0.01). Increasing quantitative AD-1 demonstrated significantly greater odds of erythema (OR 2.98, [1.53-5.82], p=0.01), purulence (OR 2.84, [1.51-5.35], p=0.01), fever (OR 1.84, [1.15-2.93], p=0.01), threatened exposure (OR 2.97, [1.48-5.95], p<0.01), and implant exposure (OR 1.79, [1.04-3.08], p=0.04). A sub-group analysis was performed to determine the distribution of AD-1 levels based on clinical signs or symptoms. Interestingly, the range of quantitative AD-1 level was widely distributed in breasts with erythema (median=3.79, IQR 0.12-5.83, min=0.05) (Figure 1), whereas variance in AD-1 was minimal for breasts with purulence (median=4.10, IQR 3.0-5.7, min=2.7). Increasing AD-1 increased odds of requiring oral antibiotics (OR 2.96, [1.53-5.73], p=0.01), IV antibiotics (OR 2.02, [1.1-3.71], p=0.02), washout (p<0.01), and explant (OR 2.48, [1.47-4.2], p<0.01). Increasing AD-1 positively correlated with WBC count (β=1.8 cells/microliter, p<0.01), and lactate (β=0.19 meq/liter, p<0.04). Ordinal logistic regression analysis demonstrated that quantitative AD-1 level was an independent predictor of infection severity (χ²=22.77, p<0.01). AD-1 level was a significant predictor of infection severity (Wald=22.77, p<0.01), with higher levels associated with greater infection severity. The parameter estimate for AD-1 suggests that the average infection score increased by 1.20 (95% CI [0.73, 1.78]) for every one-unit increase in AD-1. Conclusion AD-1 levels correlate with infection severity, highlighting its potential as an indicator of patient prognosis in intermediate infections, when clinical exam may only demonstrate an erythematous breast. Accurate and rapid classification of infection severity is imperative, as a growing cohort of plastic surgeons now attempt to manage mild infections or threatened exposure without exclusive implant removal. While further evaluation is warranted, AD-1 may have utility in novel implant salvage algorithms following breast reconstruction.

Introduction Gigantomastia is a disease characterized by excess breast growth resulting in back pain, postural imbalance, intertrigo, and psychosocial disablement. There are multiple surgical techniques utilized in breast reduction surgery, with free nipple grafting (FNG) often being the technique of choice in large reductions. Here, we provide evidence that medial pedicle wise-pattern technique (MPWP) is also a safe surgical technique for treating gigantomastia and has strengths over FNG and other reduction techniques.

Methods We reviewed our institution's electronic medical record system between February 2020 to February 2023 to identify women diagnosed with gigantomastia whom underwent a bilateral reduction with greater than 1,500 grams resected in at least one breast. We analyzed patient comorbidities, operative variables, and outcomes such as wound complications, need for revisions, and loss of nipple areolar complex (NAC) sensitivity. A multinomial logistical regression was utilized to identify associations between variables.

Results There were 31 patients diagnosed with gigantomastia who underwent bilateral mammaplasty. The average patient age and total bilateral resection weight was 39 years and 3828 grams. The patient average BMI was 40 kg/m2 with the most common comorbidities being hypertension (38%), diabetes mellitus (16%), and hyperlipidemia (10%). 26% of patients were either current or former cigarette users.

Medial pedicle with wise pattern skin reduction was the most common surgical technique (65%) followed by inferior pedicle (16%), superior medial pedicle (10%), FNG (6%) and superior pedicle (3%). Postsurgical drains were commonly used (94%). The most common complications were sensation loss to the NAC (16%) and minor wound dehiscence (16%). In total, 23% of all patients had decreased or complete loss of sensation to the NAC. All complications were treated out-patient and no patients required reoperation.

A multinomial logistical regression found that reduction technique was not associated with increased odds of having a surgical complication (OR=0.75, p=0.273, CI=[0.44, 1.26]). Additionally, age, excision amount, use of postsurgical drains, and BMI were not associated with increased complications (p=0.29, p=0.55, p=0.74, p=0.41). Interestingly, rates of sensation loss to areola were higher in patients with higher BMIs; however, it was not statistically significant (p=0.051). Limitations of this study include a small sample size; however, gigantomastia is relatively rare condition.

Conclusions The MPWP reduction technique is a viable option for the treatment of gigantomastia, with notable advantage of preserved nipple sensation. While FNG is the most commonly used technique for large breast reductions, it generally constitutes a loss of sensation to the NAC post-operatively. The majority of our patient population maintained full sensitivity to NAC after a MPWP reduction without experiencing an increase in other common surgical complications. Further research with a larger sample size is warranted, but the results demonstrate that a medial pedicle technique can be safely utilized in bilateral mammoplasties in patients with gigantomastia.

Introduction The driving force for many seeking plastic surgery is to feel more comfortable in their own body. Along with comfort comes satisfaction, improved self-awareness, and potential change in interoceptive awareness. Interoceptive awareness is defined as the conscious perception of one's body.1 While the ability to consciously perceive bodily signals can be influenced by many factors, sense of self and body image play a significant role.2 Studies have shown diminished interoceptive awareness in those with negative and distorted body images, but no research has assessed the impact of a change in body image (via plastic surgery) on interoceptive awareness.3 Therefore, the purpose of this study is to investigate how interoceptive awareness changes after receiving breast surgery in cis-gendered women.

Methods To quantify interoceptive awareness, the Multidimensional Assessment of Interoceptive Awareness Version 2 (MAIA-2) was administered to women, 19 years or older, undergoing breast surgery at Nebraska Medicine and the University of Nebraska Medical Center.4 A baseline survey was administered preoperatively, with follow up surveys at one week, one month, and three months postoperatively. Data was collected from 16 women through 3 months post-operative, 7 women through 1 month, and 12 women through 1 week. Data was analyzed using a Wilcoxon signed ranks test to compare median baseline values of each of the 8 MAIA-2 subcategories with its follow up counterpart, as well as overall survey averages.

Results Using exact significance, significant increases were found at 3 months for "Not Worrying" (p=0.046) and "Emotional Awareness" (p=0.004). A significant decrease was found at 3 months for "Self-Regulation" (p=0.021). "Trust" showed significant increases at 1 week (p=0.026) and 1 month postoperative (0.038). Average scores encompassing all 8 subcategories were significantly increased at one week (p=0.018) and one month postoperative (p=0.038). There were no significant changes in the subcategories of "Noticing," "Not Distracting," "Attention Regulation," or "Body Listening."

Conclusion From this study, it can be concluded that breast surgery has a positive impact on interoceptive awareness at one week and one month postoperative. These findings are clinically relevant in that they may offer providers an insight into the psychological outcomes of a breast procedure. A comprehensive understanding of the effects of a procedure enables providers to educate patients not only on anticipated physical results, but also on potential changes in sense of self--for which is the desire of surgery for many.

References 1. Craig, A.D., How do you feel? Interoception: the sense of the physiological condition of the body. Nature Reviews Neuroscience, 2002. 3(8): p. 655-666. 2. Pollatos, O., et al., Reduced perception of bodily signals in anorexia nervosa. Eat Behav, 2008. 9(4): p. 381-8. 3. Brown, T.A., et al., Psychometric Evaluation and Norms for the Multidimensional Assessment of Interoceptive Awareness (MAIA) in a Clinical Eating Disorders Sample. Eur Eat Disord Rev, 2017. 25(5): p. 411-416. 4. Mehling, W.E., et al., The Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2). PLOS ONE, 2018. 13(12): p. e0208034.

Introduction: Breast reconstruction with autologous tissue, such as abdominal fat, has been used to restore form after multi-modal treatment including chemotherapy, surgical extirpation, and local tissue radiation.1 Nonetheless, little is known about the regenerative mechanism of fat when transferred from one part of the body to the chest wall for breast reconstruction. This is particularly pressing, given the rich proteins and progenitor cells, including adipose derived stem cells (ASCs), within the stromal vascular fraction (SVF or stromal vascular cells, SVCs) of fat. The purpose of this work was to develop a model of engineered adipose tissue grafts supplemented with stromal or stem cells for soft tissue regeneration.

Methods: Discarded lipoaspirate from a healthy female donor was processed according to clinical standard. Tissue scaffolds were then implanted on the dorsal flank of nude mice for 8 weeks. A 2 x 2 grid was devised on the flanks with 0.5mL of graft (or saline ASC control) in each square so that each animal contained all treatment and control scaffolds. Engineered grafts were supplemented with either culture expanded pure ASCs or admixed cells from the SVF (SVCs) from the same surgical procedure. Standard grafts and cell mixture without fat were used as controls. Graft retention was measured over time. At 8 weeks, animals were sacrificed, and tissue specimens were processed for volume, histology, and protein expression. Protein concentrations were measured using the Proteome Profiler Human XL Cytokine Array Kit. The images were analyzed using ImageJ software.

Results: The ASC/saline control had dissipated over the 8-week study. The standard graft (controls) had 59.2% graft retention. Adipose scaffolds supplemented with pure ASCs and SVCs demonstrated higher volume retention at 8 weeks (76.6% vs. 77.3% respectively). Protein assessment in the tissue constructs at 8 weeks demonstrated variations in cytokine concentrations between cell-controls and engineered grafts. All grafts expressed comparable concentrations of markers of adipogenesis and functional adipose tissue (adiponectin, leptin) with minimal expression in the ASC controls. The SVF supplemented adipose scaffold cells had higher expressions of inflammatory markers such as C reactive protein and the ST2 signaling protein. Grafts engineered with pure ASCs demonstrated higher concentrations of remodeling proteins including hepatocyte growth factor, matrix metalloproteinase 9, and vascular endothelial growth factor. Of note, all grafts had comparable expression of CD31, a marker for neovascularization.

Conclusions: The model developed in this pilot study will set way for an optimal design in which cell-tissue specific scaffolds can target soft tissue fibrosis and radiation injury. We were able to identify differences in cytokine expression in the graft and the associated SVF, particularly in inflammation and wound healing. These secretomes may impact graft retention and fat necrosis in the clinical setting but more importantly allow for goal-directed graft engineering to target regeneration and repair radiation injury in comprehensive cancer treatment.

1. Hanson SE, Kapur SK, Garvey PB, et al. Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy. Plast Reconstr Surg. 2020;146(2):215-225.

Background: Locoregional anesthesia can reduce opioid consumption and post-discharge pain after breast reconstruction. The objective of this study was to describe trends in disparities amongst patients undergoing postmastectomy breast reconstruction with tissue expanders (TE). Methods: Our institutional database was used to retrospectively identify patients who underwent TE placement from 2017 to 2022. Patients were included if they had the aforementioned procedure and available data on receipt of regional anesthesia. Patient demographics were recorded and cases were grouped by receipt of regional block. Interpreters were used for all non-English speaking patients. Results: 4467 patients underwent breast reconstruction with a TE and all were offered a block as part of a standard mastectomy pain protocol; 85% accepted and 15% declined. White women were significantly more likely to receive regional anesthesia than not, with only 14% refusing. Black women and women identifying racially as "Other" were significantly more likely to decline regional anesthesia (20% of Black patients and 19% of "Other" patients). There was no difference in block receipt for Asian patients. A significantly larger proportion of Hispanic patients (8.8% vs. 12%, p=0.029), and patients whose primary language was not English (i.e., Spanish or Other) did not receive a block (1.2% vs. 3.0%, p<0.001 for native Spanish speakers; 1.8% vs. 3.1%, p=0.029 for other native languages). Alternatively, native English speakers were significantly more likely to receive a block (97% vs. 94%, p<0.001). There were also significant differences in block receipt and type of insurance; a larger proportion of patients with commercial insurance received a block (82% vs. 73%, p<0001), while a larger proportion of patients with Medicaid declined (5.4% vs. 11%, p<0.00). Other significant differences were found between the groups for median age, laterality, and median BMI. Using a logistic regression model, undergoing unilateral surgery reduced the odds of receiving regional anesthesia (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.61-0.87; p<0.001), as did having Medicaid (compared to commercial insurance) (OR, 0.53; 95% CI, 0.39-0.72; p<0.001). Conclusion: Effective pain management is crucial for the rehabilitation of patients after surgery. Given its benefits, the use of regional anesthesia in breast reconstruction is increasing. However, even at an institution with an established pathway for pain control, where all patients are offered blocks, we identified differences in the receipt of locoregional anesthesia in patients undergoing TE-based breast reconstruction. Our findings parallel those which exist in the literature highlighting disparities in regional block receipt amongst mastectomy patients.1,2 These differences justify future efforts to understand the underlying causes of these inequities so we may provide equal care to all breast reconstruction patients. References 1. Beletsky A, Burton BN, Finneran JJ, Alexander BS, Macias A, Gabriel RA. Association of race and ethnicity in the receipt of regional anesthesia following mastectomy. Region Anesth Pain M. Feb 2021;46(2):118-123. doi:10.1136/rapm-2020-101818 2. Mazzeffi MA, Keneally R, Teal C, et al. Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study. Anesth Analg. Jul 2022;135(1):170-177. doi:10.1213/Ane.0000000000006058

Introduction: Macromastia affects women's quality of life through back pain, neck pain, rashes, and discomfort with maneuvering daily living.¹ Conservative treatment includes weight loss, supportive bras, anti-inflammatory medication, and physical therapy (PT); however, these treatments rarely provide lasting relief.¹ Despite strong evidence that patients undergoing breast reduction improve in areas of physical, psychological and sexual wellbeing, insurance companies have continued to deny surgery even after patients have participated in various conservative treatments with no PT.¹'² High quality literature on the efficacy of PT in patients with macromastia is lacking, but a small prior studies did not demonstrate PT to provide full permanent relief of the symptoms.³ The purpose of our study was to expand on the role of conservative treatment in macromastia by assessing the impact of PT versus surgery and characterize patient factors associated with progression from PT to surgery.

Methods: We conducted a retrospective cohort study of patients diagnosed with macromastia who had an appointment with a plastic surgeon at University of Colorado Hospital from 2017 to 2020. Patient charts were reviewed and information was collected on patient-reported symptoms, patient characteristics, conservative treatments, physical therapy duration, and reported effectiveness. Whether patients ultimately progressed to surgical treatment was also collected. All patients were identified prior to chart review to minimize selection bias. Descriptive and bivariate statistical analysis was performed.

Results: A total of 200 patients with macromastia met inclusion criteria. The most common symptom was back pain (N=190, 95.0%). A total of 175 (87.6%) patients had PT. Of those, only 10 (5%) patients reported partial relief, and 95 (47.5%) proceeded with surgery. The mean time from diagnosis to surgery was 640 days, and mean time from plastic surgery consult to surgery was 252 days. Patients with military health care plans waited less time to undergo a breast reduction after their initial consult (145 days) compared to private insurance (255 days, P=0.04) or Medicaid (274 days, P=0.03). Of patients that underwent PT, 92 (52.5%) participated in more than 12 weeks of PT, and only 10 (5.71%) of the patients reported partial relief. PT duration did not show a significant correlation with patients ultimately progressing to surgery (P=0.07).

Conclusion: Patients frequently undergo PT prior to breast reduction surgery despite few experiencing significant relief and most eventually requiring definitive treatment with surgery. Conservative treatment with PT should be further studied and potentially reconsidered as an insurance company requirement prior to breast reduction. Future work by this group will focus on expanding the cohort of patients and gaining patient perspectives through a standardized survey on their symptomatic relief with PT and breast reduction.

References: 1. Rawes CMA, Ngaage LM, Borrelli MR, Puthumana J, Slezak S, Rasko YM. Navigating the Insurance Landscape for Coverage of Reduction Mammaplasty. Plast Reconstr Surg. Nov 2020;146(5):539e-547e. doi:10.1097/prs.0000000000007241 2. Wang AT, Panayi AC, Fischer S, et al. Patient-reported Outcomes After Reduction Mammoplasty Using Breast-Q: A Systematic Review and Meta-analysis. Aesthet Surg J. Nov 22 2022;doi:10.1093/asj/sjac293 3. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. Apr 15 2002;109(5):1556-66. doi:10.1097/00006534-200204150-00011

Two-stage tissue expansion has become the preferred technique for breast reconstruction. Smooth tissue expanders (STE) were introduced first, followed by textured tissue expanders (TTE), which were found to have lower complication rates and more satisfactory cosmetic outcomes than STEs. However, due to recent reports of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) occurring in association with textured devices, many have reverted to using STEs.

Due to the increased hesitation and stigma associated with using textured devices and the increased use of STEs, we performed a systematic review and meta-analysis to evaluate if there were any significant differences in the complication profile of smooth vs. textured tissue expanders. 22 papers were included, with outcomes including the following: implant rupture, infection, seroma/hematoma, skin flap necrosis, dehiscence, explantation, tissue expander malposition, and capsular contracture. For the sixteen studies that included only a single arm of data on outcomes for either TTEs or STEs, we formed an aggregate of total events in these studies for each outcome to be included in our meta-analysis.

Our meta-analysis found a significantly greater risk of explantation and capsular contracture in STEs than TTEs [odds ratio (OR) = 1.73; 95% CI = 1.26 to 2.36; P = 0.0006] and [OR = 2.47; 95% CI = 1.27 to 4.81; P = 0.008], respectively. Our meta-analysis did not find any significant differences among all other measured outcomes. There was no significant difference in implant rupture between TTEs and STEs [OR = 1.43; 95% CI = 0.63 to 3.23; P = 0.39], infection risk between the two expander texture types [OR = 0.81; 95% CI = 0.36 to 1.81; P = 0.61], skin flap necrosis in STEs and TTEs [OR = 1.24; 95% CI = 0.62 to 2.49; P = 0.54], hematoma formation in STEs and TTEs [OR = 0.92; 95% CI = 0.48 to 1.79; P = 0.81], seroma formation between TTEs and STEs [OR = 1.79; 95% CI = 0.70 to 4.53; P = 0.22], wound dehiscence risk between TTEs and STEs [OR = 1.30; 95% CI = 0.51 to 3.30; P = 0.58], and in the risk of nipple necrosis when comparing TTEs and STEs [risk difference (RD) = 0.01; 95% CI = -0.04 to 0.07; P = 0.63].

In conclusion, only the risk of explantation and capsular contracture were higher in the STE group than in the TTE group, which is consistent with previous studies. Surgeons involved in breast reconstruction should take into consideration the increased risks of capsular contracture and explantation when utilizing STEs, and compare that to the extremely rare, nonetheless potentially fatal, increased risk of BIA-ALCL with TTE use.

Objective: The deep inferior epigastric artery perforator (DIEP) flap is the current gold standard for autologous breast reconstruction. One of the aesthetic issues after skin-sparing mastectomy (SSM) and immediate DIEP flap reconstruction is optimal shape and position of the skin paddle and the overlying skin envelope, as well as nipple-areola reconstruction. We present the "snow cone" secondary revision procedure which incorporates multiple elements into a single, simple procedure.

Methods: This revision technique combines skin paddle reduction, nipple-areola reconstruction via a modified CV flap, and a vertical mastopexy (with optional horizontal component). The shape of the markings resemble a "snow cone," thereby giving the procedure its name. Data about patients who have undergone the procedure was collected, which included demographic information (age, BMI, comorbidities, and smoking history), perioperative data (previous breast surgery, chemotherapy, radiation, length of stay, and length of follow-up), occurrence of minor complications (seroma, hematoma, or superficial infection), occurrence of major complications (fat necrosis, necrosis of reconstructed nipple-areola, or deep infection), and need for subsequent revision procedures.

Results: Nine patients underwent the "snow cone" technique. In the cohort, the average age was 47 years old, and the average BMI was 27.9. Hypertension, hyperlipidemia, and autoimmune disease were the most common comorbidities (22.2%). Previous adjuvant chemotherapy had been undertaken by 7 patients (77.7%), and previous adjuvant radiation to the reconstructed breast by 4 patients (44.4%). All patients were discharged the day of the procedure. The average follow-up was 86 days. No patients experienced major complications, and only one (11%) experienced a minor complication (erythema that resolved with oral antibiotics). No additional revision procedures were needed in any patient.

Conclusion: The "snow cone" secondary revision technique is safe and effective, and should be considered in order to optimize aesthetics in patients who have undergone autologous breast reconstruction.

Purpose:

The psychosocial benefits of breast reconstruction for breast cancer patients are well documented, and yet not all patients have historically been afforded the option for reconstructive surgery. The 1998 Women's Health and Cancer Rights Act mandated insurance coverage of immediate post-mastectomy reconstruction for patients diagnosed with breast cancer, with the goal of improving access to reconstructive surgery for all patients. Despite this, analysis of trends in reconstruction following this law showed that only 42% of patients getting a mastectomy receive immediate reconstruction, with the likelihood lower for patients with Medicare and Medicaid compared to private insurance. Through this study we aim to assess current disparities in reconstructive surgery rates and explore what barriers may still exist to receiving care.

Materials and Methods:

Retrospective review identified demographic, socioeconomic, and clinical data for patients undergoing mastectomy with immediate reconstruction at Weill Cornell Medicine and Columbia University Irving Medical Center from 2002 to 2019. The primary outcome was receiving reconstruction post-mastectomy. Multivariate logistic regression identified predictors of reconstruction among patients of varying sociodemographic factors.

Results:

Our cohort includes 6,122 patients diagnosed with breast cancer who underwent mastectomy, of which 3,737 (61.04%) underwent reconstruction and 2,385 (38.96%) did not. Of those receiving reconstruction, 2,840 (76%) identified as White, 414 (11%) identified as Black, 259 (6.9%) identified as AAPI, and 50 (1.3%) identified as other. Multivariate regression revealed that age 45 and above, having public insurance, advanced tumor staging, and identity as AA/PI were negative predictors for receiving post mastectomy reconstructive surgery (p < 0.01 for all factors). In contrast, receiving supplemental chemotherapy and being in the highest income quartile were associated with increased likelihood of obtaining reconstructive surgery.

Conclusions:

Despite legislative changes to make reconstructive care more affordable and enhance communication to patients about reconstructive care options, our data indicates that not all groups are equally benefiting from improvements in access. Disparities in reconstructive surgery rates based on age, race, income, and cancer stage persist. This data emphasizes the need for further study aimed at mitigating barriers to care among these groups.

Background: Access to healthcare services, especially specialized procedures like microsurgical breast reconstruction, may be limited by geography and contribute to inequity. Although insurers, including Medicaid, may cover out-of-state services if otherwise not readily available in a patient's home state [1], little is known regarding the trends, patient populations, and payments for microsurgical breast reconstruction for out-of-state patients.

Methods: We queried the Massachusetts all-payer claims database for patients who underwent mastectomy followed by microsurgical breast reconstruction (CPT: 19364 and S2068) from 2016 to 2020 and used zip code data to identify patients who resided in Massachusetts versus out-of-state. Insurance type (private vs. public) was compared between in-state and out-of-state patients using Chi-square analysis. We compared payer reimbursements for microsurgical breast reconstruction as well as out-of-pocket patient (OOP) costs between out-of-state and in-state patients, normalizing bilateral procedures to unilateral procedures.

Results: A total of 433 patients underwent microsurgical breast reconstruction after mastectomy, of which 365 (84.3%) resided in Massachusetts and 68 (15.7%) resided out-of-state. In total, 370 patients (85.5%) were privately insured, and 63 (14.5%) were publicly insured. Out-of-state status was associated with having private insurance (97.1% vs. 83.2%, p = 0.006). The 2 patients (2.9%) who were out-of-state and publicly insured were beneficiaries of Medicare Supplemental Policy ("Medigap") and Medicaid Managed Care Organization. Of the out-of-state patients who were privately insured, 51 (75.0%) held preferred provider organization plans, 3 (4.4%) held point-of-service plans, and 10 (14.7%) held health maintenance organization plans. Mean overall physician payments (payer + OOP costs) were similar between in-state ($20,455) and out-of-state ($19,966) patients. Mean payer costs were $12,715 (in-state) and $17,880 (out-of-state). Mean OOP costs were $7740 (in-state) and $2086 (out-of-state).

Conclusions: Out-of-state patients who undergo microsurgical breast reconstruction in Massachusetts are more likely to be privately insured. Overall physician payments for microsurgical breast reconstruction are similar, regardless of a patient's home state; however, the share of cost may be higher for out-of-state payers. Public insurance policies for coverage of out-of-state procedures may contribute to disparities in access to microsurgical breast reconstruction.

1. Medicaid and CHIP Payment and Access Commission (MACPAC). Medicaid Payment Policy for Out-of-State Hospital Services. https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid-Payment-Policy-for-Out-of-State-Hospital-Services.pdf. Published January 2020. Accessed March 4, 2023.

Purpose: In recent years, increasing emphasis has been placed on sensation recovery by women undergoing mastectomy and reconstruction. Given this trend, an increasing number of studies have been conducted focusing on breast sensation restoration. These prior studies have found that mastectomy technique, reconstruction type, adjuvant irradiation, and reconstructive plane play significant factors in sensory return. However, at present, there is still a paucity in literature regarding the impact of patient comorbidities and demographics on neural regeneration. Additionally, most literature on return to sensation focuses on patients who undergo implant-based reconstructions opposed to autologous tissue reconstructions.

Methods: Women undergoing mastectomies with immediate deep inferior epigastric perforator (DIEP) flap reconstruction were identified and followed prospectively. Preoperatively and at predetermined postoperative timepoints, neurosensory testing was performed in 9 breast regions using a pressure-specified sensory device to determine 1-point static cutaneous thresholds. Values were scaled on a 0-100 point range such that higher values indicate increased sensitivity. Unpaired t-tests and ANOVA with pairwise Bonferroni corrections were used to compare average sensation scores across groups stratified by patient comorbidities, using an alpha of 0.05.

Results: 131 patients underwent neurosensory testing before or after mastectomy with either unilateral or bilateral DIEP flap reconstruction. Testing was conducted pre-operatively and at various time points post-reconstruction, stratified into <1 year, 1-2 years, 2-4 years, and 4+ years after mastectomy and reconstruction. Some patients underwent testing at multiple timepoints, accounting for a total of 418 measured breasts. Patients were stratified based on comorbidities including age, hypertension, tobacco use, alcohol use, and obesity (body mass index>30kg/m^2). At baseline, only the increased age (-0.32 sensation points/year) and the obesity (-9.24 points) groups had significant differences in breast sensation. At <1-year post-mastectomy, former (-9.99) and active (-23.2) tobacco use were significantly correlated with decreased breast sensation. At 1-2 years post-reconstruction, obesity (-16.93) and active tobacco use (-30.0.9) were found to be significant factors in sensation restoration. From 2 years after mastectomy onwards, none of the comorbidities were found to be significant predictors of breast sensation.

Conclusions: The importance of breast sensation cannot be overstated as it plays an integral role in a woman's physical and psychological wellbeing. Although comorbidities such as BMI, hypertension, and smoking play impactful roles in other components of reconstruction such as necrosis and wound healing, the comorbidities evaluated in this study did not significantly impact breast sensation long-term. Smoking status, BMI, and age significantly impacted breast sensation in the first 2 years post-reconstruction. However, these differences subsided from 2 years onwards. Our results can help guide pre-operative patient counseling on reconstruction after mastectomy and suggest that regenerative capabilities of breast sensory nerves may be largely independent of patient characteristics and comorbidities.