Scientific Abstract Presentations: Breast 6 Friday, October 27 Fri, Oct 27 5:00-6:00 p.m. CDT

BACKGROUND: In recent years, the cases of patients requesting the removal of breast implants, without replacement or placement of new implants, have increased. Simple removal of breast implants often leads to wide, deflated, and laterally displaced breasts that are notoriously difficult to reconstruct. The different mastopexy techniques seek to remove excess skin in patients who require additional cosmetic treatment after implant removal. The objective of this work is to present our experience in breast auto-augmentation with dermoglandular flaps in patients undergoing post-explantation Mastopexy; expose our surgical technique and the results obtained.

METHODS: Between March 2019 and March 2022, 50 women who underwent explantation of breast implants and subsequent mastopexy using glandular flaps were retrospectively evaluated. Circumvertical and in some cases inframammary approaches were used. Total or partial capsulectomy was performed depending on the case and the characteristics of the periprosthetic capsule. Lateral glandular flaps, superior pedicle flaps, and inferior pedicle flaps were used as autologous breast augmentation in mastopexy. Hemosuctor drainage was left in all patients. All procedures were performed by the authors. Peroperative and demographic variables were analyzed using univariate analysis. Mean follow-up of 12 months.

RESULTS: A total of 50 post breast implants removal mastopexies with auto-augmentation were performed using glandular flaps. Lateral triangular flaps were used in 40 (80%) of patients, superior pedicle flap in 5 (10%) and inferior pedicle flaps in 5 patients (10%). Lipotransference was not performed in any of the cases. Regarding complications, 1 (2%) patient presented postoperative hematoma, 1 (2%) patient presented seroma, 1 (2%) surgical wound dehiscence, and 1 (2%) required surgical revision due to recurrence of breast ptosis.

CONCLUSION: Autologous breast augmentation with dermoglandular flaps provides a reliable way to reorient breast volume and configure the anatomical shape of the breast in patients undergoing mastopexy after breast implant removal.

REFERENCES:

• Gurunluoglu R, Kubek E, Arton J. Dual pedicle mastopexy technique for reorientation of volume and shape after sub- glandular and submuscular breast implant removal. Eplasty 2013;13:e48. • Gurunluoglu R, Shafighi M, Schwabegger A, Ninkovic M. Secondary breast reconstruction with deepithelialized free flaps from the lower abdomen for intractable capsular contracture and maintenance of breast volume. J Reconstr Microsurg. 2005;21:35–41. • Hönig JF, Frey HP, Hasse FM, Hasselberg J. Inferior pedicle autoaugmentation mastopexy after breast implant removal. Aesthetic Plast Surg. 2010; 34:447–454. • Tanna, N., Calobrace, M. B., Clemens, M. W., Hammond, D. C., Nahabedian, M. Y., Rohrich, R. J., ... & Perry, A. D. (2021). Not all breast explants are equal: contemporary strategies in breast explantation surgery. Plastic and reconstructive surgery, 147(4), 808-818. • Avashia, Y. J., Rohrich, R. J., Gabriel, A., & Savetsky, I. L. (2020). Surgical management of the explant patient: an update on options for breast contouring and volume restoration. Plastic and Reconstructive Surgery, 146(5), 978-985.

Purpose: Nipple and areolar complex (NAC) reconstruction has been shown to significantly improve patient satisfaction following breast reconstruction. A wide variety of techniques are used depending on patient and provider preference. These can be categorized into surgical reconstruction, tattooing, or a combination of the two. With recent advancements in medical tattooing, there has been a growing interest in tattoo-based methods of NAC reconstruction within the breast reconstruction literature. However, to date there are no studies that examine trends in choice of NAC reconstruction method over time. This study aims to quantify recent trends in NAC reconstruction, and explore possible driving factors.

Methods: A retrospective review was conducted within the plastic surgery department of a single tertiary care hospital. Medical records of patients who underwent post-mastectomy breast reconstruction between January 2007 and December 2021 were reviewed, and those who had any type of NAC reconstruction were included. Demographic and breast reconstruction data were also collected. Patients were divided into three groups based on method of NAC reconstruction used: (1) surgical-only, (2) tattoo-only, and (3) both surgical and tattoo. Trends were assessed in each group using Poisson regression by the year. Associations between demographic variables, breast reconstruction factors, and NAC reconstruction were also assessed.

Results: The study included 138 patients; 17.4% (n=24) of the cohort underwent surgical-only NAC reconstruction, 16.7% (n=23) underwent tattoo-only NAC reconstruction, and 65.9% (n=91) had both surgical and tattoo NAC reconstruction. The mean age was 48 years. Over the course of the 15-year study period, the number of patients receiving tattoo-only NAC reconstruction significantly increased (β=0.173, p<.0001), while the number of patients receiving surgical and tattoo NAC reconstruction significantly decreased (β= -0.064, p=0.007). There were no significant changes in surgical-only NAC reconstruction (β=0.013, p=0.563) or in the total number of patients receiving any type of NAC reconstruction (β=-0.013, p=0.503). Overall rates of breast reconstruction significantly increased at this institution over the study period (β=0.062, p<0.0001). Breast reconstruction variables such as autologous vs. implant-based reconstruction, unilateral vs. bilateral, number of revisions, and use of radiation therapy were stable over time and were not significantly associated with NAC reconstruction method.

Conclusion: For many breast cancer patients, nipple-areola complex reconstruction is an important final step in the breast reconstruction process that improves satisfaction and quality of life. This study demonstrated a significant trend toward tattoo-only reconstruction and away from surgical-only reconstruction over the past 15 years, highlighting the importance of patient access to tattoo-based nipple reconstruction as part of comprehensive breast reconstruction care. In addition, the timing of the trend corresponds well with known advances in nipple tattooing technology and techniques, suggesting that increased tattoo quality could be contributing to these findings. Further study may illuminate additional reasons for this demonstrated increase in popularity of tattoo-based nipple-areola complex reconstruction.

Background: Intraoperative fentanyl is one of the most frequently administered intraoperative narcotics and may increase the risk of perioperative complications including nausea, constipation, antiemetic use, and respiratory complications. We previously used liposomal bupivacaine to reduce intraoperative fentanyl use. However, it became unavailable for use in our institution and a substitution of plain Ropivacaine was utilized. Previous studies reviewed a significant reduction in intraoperative fentanyl use with liposomal bupivacaine. We wanted to see if there was a difference in intraoperative Fentanyl use between liposomal bupivacaine and Ropivacaine.

Methods: A case matched review of 68 (34 in each group) reduction mammplasty patients was performed. We analyzed the total use of intraoperative fentanyl use in patients with intraoperative administration of liposomal bupivacaine vs. patients injected with Ropivacaine. All patients received IV Tylenol prior to reversal.

Results: Intraoperative administration of liposomal bupivacaine vs. Ropivacaine showed no significant difference in intraoperative fentanyl use (P value 2.2608).
Ropivacaine is an amide local anesthetic with an action time longer that that of lidocaine.

Conclusions: Prior studies revealed that liposomal bupivacaine significantly reduces intraoperative fentanyl use. This recent reveals that Ropivacaine can be utilized as a substitute for liposomal bupivacaine where unavailable. Initial data reveal an increase in the use of postoperative oral narcotics in the Ropivacaine group vs. the liposomal bupivacaine group. This may be due to the 3-6 hour duration of Ropivacaine vs. 24-72 hour druation of liposomal bupivacaine.

Background Prepectoral implant placement continues to gain widespread acceptance as a safe and effective option for breast reconstruction. Recent advances in surgical techniques have stimulated renewed interest, including refinements in mastectomy procedures and the advent of mesh to improve lower pole shape and projection. It is also believed to mitigate the effects of radiation, including reconstructive failure and muscle fibrosis. Current literature demonstrates comparable rates of complications and revisional surgeries between prepectoral and subpectoral placement; however, these studies are often underpowered and lack long-term follow-up.

Methods We performed a retrospective cohort study of patients who underwent immediate two-staged tissue expander or direct-to-implant breast reconstruction with the use of acellular dermal matrix at a single center from January 2017 to March 2021. Cases were divided into prepectoral and subpectoral cohorts. Baseline patient characteristics were obtained. The primary outcomes were any postoperative complication and rate of secondary procedures. Secondary procedures were defined as fat grafting, breast mound revisions, and conversion to autologous flaps. Univariate and multivariable regression models were used to assess risk associations between the type of reconstruction and outcomes of interest. A subgroup analysis was performed to compare outcomes in those who received adjuvant radiation.

Results We identified 996 cases (570 females), of which 97% of patients completed reconstruction. These were divided into prepectoral (n=391) and subpectoral (n=605) cohorts. Mean follow-up was 24 and 14 months for two-stage tissue expander and direct-to-implant reconstruction, respectively. The prepectoral cohort underwent a higher rate of direct-to-implant reconstructions and had higher initial fill volumes at the time of tissue expander placement. The subpectoral group underwent a higher rate of prior breast surgeries and higher rate of expander to implant exchange. Univariate analysis demonstrated a higher rate of any complications (p<0.001) with prepectoral breast reconstruction, including both major (p<0.001) and minor (p=0.02) complications. Secondary procedures after implant exchange were overall higher in the subpectoral cohort (

Conclusion This study evaluated surgical outcomes in patients undergoing either prepectoral or subpectoral breast reconstruction from a single center with long-term follow-up. Prepectoral placement was shown to have an inferior complication profile compared to subpectoral placement, with no difference in secondary procedures. These findings require validation with a well-designed randomized controlled trial to establish best practice for implant-based breast reconstruction.

Background: Oncoplastic surgery (OPS) in breast cancer facilitates high-volume excision while optimizing the aesthetic result. These techniques are cost effective (1) and have improved patient satisfaction compared to other surgeries. The reported frequency of short-term complications associated with OPS is low , but there is little evidence that compares these findings to mastectomy. Our aim was to compare the frequency and risk factors of postoperative complications between OPS and mastectomy. As a secondary objective, we determined breast cancer-specific survival differences between both procedures.

Materials and methods: Patients with breast cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) Medicare Database from 2012 to 2017. We included females with stages I-II breast cancer who underwent oncoplastic surgery with radiotherapy and mastectomy without radiotherapy. Complications with ICD-9/10 and procedures with CPT (Computer Procedural Terminology) codes were obtained from the MEDPAR, outpatient, and NCH databases. Descriptive statistics were performed, chi-square and t-student tests were used for qualitative and quantitative analysis, respectively. Logistic regression analysis was used to assess risk factors for overall and individual complications.

Results: Of 53,649 patients identified, 73.2% of patients were ≥65 years old (median:69, range: 23-100). OPS and mastectomy were performed in 1,053 (2%) and 52,596 (98%) patients respectively. The majority of patients had invasive ductal carcinoma (73.3%), low-intermediate grade (67.4%), and HR+/HER2 negative (63.5%). 57.2% and 52.8% were diagnosed in stage I and II, respectively. OPS was performed more frequently in white race (89.4% vs 80.3%, p<0.001), married patients (59.5% vs. 50.9%, p< 0.001), low-intermediate histologic grade tumors (75.1% vs. 71.9%, p=0.029). Mastectomy was more commonly performed for triple-negative tumors (10.9% vs 6.8%, p=0.001), patients with poverty indicator ≥10% (52.1% vs 41.8%, p<0.001), and stage II ( 42.9% vs. 37.3%, p<0.001). Complications were reported in 2.1% patients, regardless of procedure type with no significant difference. (OPS 1.9% vs. mastectomy 2.1%, p=0.64). Similarly, no differences were found in seromas (0.6% vs. 0.3%, p=0.052), hematomas (0.9% vs. 1.0%, p=92), infection (0.3% vs. 0.7%, p=0.11), wound dehiscence (0.1% vs 0.2%, p=0.35), or microvascular complications (0% vs.0.1%, p=0.39). Multivariate analysis demonstrated that procedure type was not a risk factor for overall (OPS vs. mastectomy, OR=0.97, 95% CI:0.60-1.58, p=0.90) or individual complications. Independently to the stage, patients who underwent OPS had better breast cancer-specific survival (BCSS) with a median follow-up of 49 months compared to mastectomy at 5 years follow-up (Stage I:98.9% vs. 96.6% p=0.006; Stage II: 96.6% vs. 89.8%% p<0.001).

Conclusions: Oncoplastic surgery has demonstrated a low incidence of surgical short-term complications which are comparable to mastectomy in stages I-II breast cancer patients. Moreover, OPS has shown to favor BCSS over mastectomy independently to the stage at diagnosis. Further prospective studies are needed to assess whether this trend continues with locally advanced breast cancer and long-term oncologic outcomes.

References 1) Chatterjee A, Asban A, Jonczyk M, Chen L, Czerniecki B, Fisher CS. A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with free flap reconstruction in the treatment of breast cancer. Am J Surg. 2019 Sep;218(3):597-604.

Introduction The deep inferior epigastric perforator (DIEP) flap is the preferred method for autologous breast reconstruction following mastectomy, though it risks development of hernia, bulge, or decreased core strength.1 Robotic-assisted surgery began in the 1980s and has quickly evolved to become gold standard in many fields.2 Robotics have also begun to be utilized in plastic surgery. We are successfully performing robotic-assisted intracorporeal harvest of DIEP vessels to limit abdominal wall morbidity through smaller fascial incisions and preservation of motor nerves when compared to standard DIEP.3 Traditional DIEP flap reconstruction is already a demanding and time-consuming operation, and surgeons with limited robotic experience may initially be hesitant to attempt robotic harvest. This study shows the expected learning curve (LC) for surgeons interested in incorporating this into their practice and to compare the LC between a single general surgeon (GS) and plastic surgeon (PS).

Methods A retrospective cohort study was performed for patients who underwent robotic DIEP flap harvest from October 2021 through September 2022. We evaluated robotic pedicle dissection time (DT) and compared the times between a GS and PS. We calculated LC for each surgeon using the cumulative sum (CUSUM) method. CUSUM is the summation of differences between DT for each patient and the mean DT for all patients, CUSUM = ∑_(i=1)^n(xi-▁(µ)). LC was identified as the peak of the CUSUM curve.

Results 44 flaps were performed during the collection period: 27 by the PS, 17 by the GS. There was no significant difference in DT between the GS (34.8 min) and PS (41.2 min) (p value=0.232), and while both surgeons saw a decrease in DT over time, the DT time for the GS decreased more quickly. Using the CUSUM method, we see the peak of the curve at patient 8 for the PS and the peak of the curve at patient 5 for the GS, after which cumulative DT decreased. There were no intraabdominal or pedicle injuries in any of these patients.

Conclusion As robotic harvest of DIEP flaps becomes accepted, surgeons who wish to incorporate our technique into their practice can expect to have a consistent decrease in their DT after 10 cases. Plastic surgeons can safely and proficiently uptake the minimally invasive technique with a similar learning curve compared to robotic trained general surgeons.

References 1. EA Bailey and SN Bishop. (2023). Minimally Invasive Surgery in Breast Reconstruction: The Past and Future. Breast Cancer Updates [Working Title]. Doi: 10.5772/intechopen.109503 2. G Garas and A Arora. Robotic Head and Neck Surgery: History, Technical Evolution and the Future. ORL 2018; 80(3-4):117-124. Doi: 10.1159/000489464 3. EA Bailey, B Chen, W Nelson, S Nosik, R Fortunato, A Moreira, D Murariu. Robotic versus Standard Harvest of Deep Inferior Epigastric Artery Perforator Flaps: Early Outcomes. PRS - Global Open 2022; 10(10S):p 64-65. Doi: 10.1097/01.GOX.0000898644.00762.77

Background: Artificial intelligence (AI) offers an approach to predictive outcomes using machine learning (ML) algorithms for pattern recognition1,2 and decision-making3,4 that can be used to prevent undesirable results.5 This systematic review aimed to evaluate the usefulness of AI in breast reconstruction. Methods: A systematic review was conducted in August 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, EMBASE, SCOPUS, and Google Scholar online databases were queried to capture all publications studying the use of artificial intelligence in breast reconstruction. Results: After removing duplicates, 23 studies were full-text screened, with 12 fulfilling our inclusion and exclusion criteria. Almost all of these studies utilized ML as the AI technique implemented. The ML algorithms employed for predicting neuropathic pain, lymphedema diagnosis, microvascular abdominal flap failure, donor site complications related to muscle sparing Transverse Rectus Abdominis flap, surgical complications, financial toxicity, and patient-reported outcomes after breast surgery demonstrated that AI is a reliable tool for predicting patient results. Moreover, one study used Computer Vision technology to aid in the Deep Inferior Epigastric Perforator Artery flap design, significantly reducing the preoperative time compared to manual identification. Conclusions: AI can benefit breast reconstruction surgery by optimizing preoperative patient counseling to predict potential adverse outcomes. This, in turn, enables timely interventions and reduces the post-operative burden, resulting in optimal outcomes and increased patient satisfaction. References

1. Badillo S, Banfai B, Birzele F, et al. An Introduction to Machine Learning. Clin Pharmacol Ther. Apr 2020;107(4):871-885. doi:10.1002/cpt.1796
2. Lou SJ, Hou MF, Chang HT, et al. Machine Learning Algorithms to Predict Recurrence within 10 Years after Breast Cancer Surgery: A Prospective Cohort Study. Cancers (Basel). Dec 17 2020;12(12)doi:10.3390/cancers12123817
3. Yin J, Ngiam KY, Teo HH. Role of Artificial Intelligence Applications in Real-Life Clinical Practice: Systematic Review. J Med Internet Res. Apr 22 2021;23(4):e25759. doi:10.2196/25759
4. Liang X, Yang X, Yin S, et al. Artificial intelligence in plastic surgery: applications and challenges. Aesthetic Plastic Surgery. 2021;45(2):784-790.
5. Fu MR, Wang Y, Li C, et al. Machine learning for detection of lymphedema among breast cancer survivors. Mhealth. 2018;4:17. doi:10.21037/mhealth.2018.04.02

Purpose: Preprectoral breast reconstruction has several proposed advantages including reduced pain, morbidity, and subsequent animation deformity. Adequate control of the mastectomy pocket with proper positioning of the breast prosthetic is essential in these cases. Soft tissue support (STS), such as acellularized dermal matrix (ADM), has contributed to the rise of prepectoral breast reconstruction by facilitating the ability to shape the prepectoral breast pocket. Its use, however, introduces added cost to the initial reconstruction and continual investigation of its utility and outcomes is warranted. This study assesses the impact of using STS in prepectoral breast reconstruction.

Methods: A chart review of all consecutive, prepectoral tissue expander reconstructions performed between March 2017 and July 2022 at a single center was conducted. Patients from a total of 5 distinct breast surgeons and 5 plastic surgeons were included. Demographics, operative characteristics, and complications were extracted for all patients. Major complications were defined as any complication involving the breast that required readmission or reoperation while minor complications included any breast complication requiring outpatient antibiotics, procedures, or wound care. Multivariate logistic regression was used to predict complications while controlling for STS. A p<0.05 was considered statistically significant.

Results: A total of 184 patients (292 breasts) were included. STS was used in 61 (21%) breasts. Type of STS included ADM (77%), ADM and vicryl mesh (3%), polydioxanone mesh (13%), and other (7%). On average, women were 53 years old, non-smoker (99%), non-diabetic (91%), and had a body mass index of 28. All breasts underwent immediate reconstruction following prophylactic mastectomies in 33% and therapeutic mastectomies in 67% of cases. The majority of mastectomies were skin sparing (61%), followed by nipple sparing (24%), simple (12%) and other (3%). Seventy-one (24%) breasts were radiated (77% adjuvant, 20% prior radiation, 3% both), and 89 (48%) patients received chemotherapy (19% adjuvant, 4% neoadjuvant, 1% both). Average follow up was 27 months. Median mastectomy weight was 551 grams, average intraoperative TE fill was 194 ± 163 ccs, and average final TE fill was 416 ± 159 ccs; none of these differed by the use of STS. Major complications occurred in 61 (21%) breasts while minor complications occurred in 85 (29%) of breasts. On univariate analysis, STS was associated with fewer minor complications (15% vs. 33%, p<0.01). In multivariable models controlling for age, BMI, mastectomy weight, radiation, intraoperative TE fill, and soft tissue support, STS was associated with fewer minor complications (OR 0.36 [0.16-0.76], p=0.01) and a weak association with fewer seromas (0.40 [0.14-1.11], p = 0.08) and a lower rate of explantation (0.40 [0.13-1.02], p = 0.08).

Conclusions: In this study, STS use in prepectoral tissue expander reconstruction reduced postoperative complications in the immediate postoperative period. Further investigation is warranted to analyze overall costs and long-term reconstructive and aesthetic outcomes between these two cohorts.

Background: Ketorolac is a well described adjunct in peri-operative pain control and enhanced recovery after surgery protocols. Ketorolac's mechanism of action functions as analgesic and platelet aggregation inhibitor. A recent study suggests ketorolac is not associated with increased hematoma risk in reconstructive breast procedures. However, only 11 patients underwent autologous reconstruction and the type of autologous reconstruction is not specified.1 An assessment of transverse rectus abdominus flaps from the year 2000 demonstrates no increased hematoma risk postoperatively, yet excludes deep inferior epigastric perforator (DIEP) flaps.2 Ketorolac is yet to become fully adopted in free tissue transfer surgery due to procedures involving large surface areas, extensive soft tissue undermining, and donor site morbidity. Complications related to ketorolac administration remain poorly described in breast free flap surgery. Our study aims to examine the impact of ketorolac on complications and free flap outcomes in DIEP based breast reconstruction.

Methods: An IRB approved retrospective chart review was completed for 525 patients who underwent DIEP free flap breast reconstruction from January 2019-March 2022. Patients were separated based on whether they received ketorolac perioperatively or not. Analysis was completed using Chi-Squared testing and multivariate regression.

Results: We describe results from 525 patients, and 863 DIEP flaps for breast reconstruction. Peri-operatively 94 patients received ketorolac and 431 patients did not. Regarding patient demographics, the ketorolac group had an average age of 47.8 years, the non-ketorolac group averaged 51.4 years (p< 0.05). The overall incidence of patients who received ketorolac and developed a clinical hematoma was 5.3% compared with 5.3% in the non-ketorolac group (p > 0.05). The incidence of hematoma requiring operative intervention was 4.3% in the ketorolac group compared with 2.6% in the non-ketorolac group (p>0.05). There was a significantly higher rate of skin necrosis in the ketorolac group. The difference in rates of skin necrosis was no longer observed when controlling for smoking. No difference was observed in free flap failure rates. No difference was observed in fat necrosis, partial flap loss, microvascular complications and PE/DVT. Mean length of follow up of the ketorolac group was 265.6 days and the non-ketorolac group was 310.4 days.

Conclusions: No significant differences in bleeding complications were identified when comparing patients who received ketorolac and those who did not. This data set represents the largest analysis of ketorolac effects in breast free flap surgery to date. The concern for increased bleeding complications is not borne out in a large data set. There was no difference in overall free flap failure. Ketorolac should be integrated and thoughtfully used perioperatively in breast free flap reconstruction without concern for increased bleeding complications secondary to ketorolac administration.

References: 1. Nguyen BN, Barta RJ, Stewart CE, Heinrich CA. Toradol following Breast Surgery: Is There an Increased Risk of Hematoma? Plast Reconstr Surg. 2018 Jun;141(6):814e-817e. doi: 10.1097/PRS.0000000000004361. PMID: 29750761. 2. Sharma S, Chang DW, Koutz C, Evans GR, Robb GL, Langstein HN, Kroll SS. Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction. Plast Reconstr Surg. 2001 Feb;107(2):352-5. doi: 10.1097/00006534-200102000-00009. PMID: 11214049.

Purpose: The introduction of acellular dermal matrix (ADM) revolutionized prepectoral breast reconstruction by providing a barrier of support between an implant and a relatively thin mastectomy flap. Despite its current widespread in breast cancer patients, previous studies have associated ADM with increased rates of various complications including seroma, infection, and reconstructive failure. Only two existing studies have previously evaluated the influence of ADM thickness on reconstructive outcomes, both of which have conflicting conclusions regarding safety.1,2 The purpose of this study is to evaluate whether ADM thickness has an impact on surgical outcomes of prepectoral implant-based breast reconstruction.

Methods: The authors completed a retrospective review of breast reconstruction cases from six surgeons at a single institution over a five-year period from January 2017 to December 2022. Only patients that received prepectoral implant-based reconstruction with ADM were included for further analysis. Information including the number of stages and the timing of reconstruction was extracted from patient charts. The incidence of four separate complications (infection, wounds or dehiscence, seroma, hematoma) was determined, in addition to the rates of reoperation for a complication and implant removal.

Results: A total of 547 patients received 849 prepectoral breast reconstructions. Of these patients, 281 received direct-to-implant (DTI) reconstruction (%) while the remaining 266 patients (%) underwent staged tissue expander (TE) reconstruction. Average patient age was 52.8 years and body mass index 26.9 kg/m2. Twenty percent of all patients (n=113) developed one of the evaluated complications, with 18% (n=97) requiring reoperation and 15.6% (n=80) necessitating operative implant removal. Patients with medium thickness ADM had significantly fewer complications than patients with either thick (29% vs 48%; p<0.0004) or extra-thick ADM (29% vs 54%; p<0.0001). Compared to extra-thick ADM specifically, patients that received medium thickness ADM had fewer infections, which approached significance (13% vs 20%; p=0.0652). Medium thickness ADM was also associated with significantly fewer incidences of wounds or dehiscence compared to both thick (14% vs 39%; p<0.0001) or extra-thick ADM (14% vs 43%; p<0.0001). DTI reconstruction had an impact on reconstructive outcomes only in the extra-thick ADM cohort, with patients that received DTI and extra-thick ADM having a significantly greater incidence of overall complications (p<0.0069), wounds (p<0.0028), and reoperation (p<0.0221) compared to patients that received staged TE reconstruction.

Conclusion: Patients that receive prepectoral implant-based breast reconstruction with medium thickness ADM may have fewer overall complications and incidence of wounds or dehiscence compared to patients that receive thicker ADM variations. Significant differences in the rate of complications for patients that received DTI versus staged TE expander reconstruction were only observed in patients with extra-thick ADM. Further prospective and randomized studies are warranted to definitively establish the relationship between ADM thickness and reconstructive outcomes.

1. Rose JF, Zafar SN, Ellsworth Iv WA. Does acellular dermal matrix thickness affect complication rate in tissue expander-based breast reconstruction? Plast Surg Int. 2016;2867097.
2. Hong SE, Kim JH. The relationship of human acellular dermal matrix thickness on complication rate and patient-reported outcomes in implant-based immediate breast reconstruction. Gland Surg. 2021;10:90-100.