Scientific Abstract Presentations: Breast 7 Saturday, October 28 Sat, Oct 28 10:30 a.m.-12:30 p.m. CDT

Background Pre-pectoral breast reconstruction has led to lower post-operative pain scores and a trend towards earlier patient discharge.1,2 Additionally, since the rise of the COVID-19 pandemic in 2020, there has been a significant transition of mastectomies and alloplastic breast reconstruction to the outpatient setting.3 The goal of this study was to evaluate the feasibility and outcomes of outpatient pre-pectoral tissue expander reconstruction.

Methods A retrospective review was performed of all patients undergoing mastectomy with immediate pre-pectoral tissue expander reconstruction at a single institution from January 2018 to July 2022. Autologous reconstruction and direct-to-implant cases were excluded. Patient demographics, oncologic and reconstructive characteristics, and post-operative outcomes were recorded. Categorical variables were compared using Fisher exact tests and continuous variables were analyzed using Kruskal-Wallis and Wilcoxon rank-sum tests.

Results A total of 295 patients and 499 breast reconstructions were analyzed. Median follow-up time was 11 months (interquartile range 6.0-18.0). 259 patients (88%) were treated at the main inpatient hospital and 36 (12%) were treated at the outpatient surgery center, which has overnight observation capabilities. The two groups were not significantly different in background characteristics, comorbidity scores, or type of mastectomy received (skin-sparing, nipple-sparing, or modified radical). Rate of acellular dermal matrix use was higher in the inpatient hospital group compared to the outpatient surgery center group (96% vs 86%, p=0.015). There was a significantly higher rate of same-day discharge among patients treated in the outpatient surgery center (8% vs 39%, p<0.001). Post-operative rates of chemotherapy and radiation therapy were comparable between the two groups. Major complications, including infection, hematoma, seroma, or mastectomy flap necrosis requiring readmission or return to the operating room, were similar between the inpatient hospital and surgery center groups (21% vs 19%, p=0.850). Subgroup analysis of patients treated during the COVID-19 pandemic (after March 2020) similarly revealed no significant difference in major complications between the inpatient hospital and surgery center groups (21.8% vs 17.3%, p=0.465). Median time to final implant placement was not significantly different between the two groups (5.0 months vs 4.0 months, p=0.181). Rate of revision surgery after implant exchange was similar in the two groups (17% vs 9%, p=0.213).

Conclusions Patients undergoing immediate pre-pectoral breast reconstruction in the outpatient setting experience no significant difference in post-operative complications, time to final reconstruction, and number of revision procedures compared to patients treated in the inpatient setting. These findings support the safe transition of immediate pre-pectoral breast reconstruction to the outpatient setting.

References 1. Walia GS, Aston J, Bello R, et al. Prepectoral Versus Subpectoral Tissue Expander Placement: A Clinical and Quality of Life Outcomes Study. Plast Reconstr Surg Glob Open. 2018;6(4). doi:10.1097/GOX.0000000000001731 2. Li Y, Xu G, Yu N, Huang J, Long X. Prepectoral versus subpectoral implant-based breast reconstruction: A meta-analysis. Ann Plast Surg. 2020;85(4):437-447. doi:10.1097/SAP.0000000000002190 3. Rubenstein RN, Stern CS, Plotsker EL, et al. Effects of COVID‐19 on mastectomy and breast reconstruction rates: A national surgical sample. J Surg Oncol. 2022;126(2):205. doi:10.1002/JSO.26889

Introduction: Surgical site infection (SSI) is one of the leading causes for post-op complications in implant-based breast reconstruction. Currently there is no consensus on the appropriate prophylactic use of antibiotics and antiseptics in implant-based breast reconstruction. This study aims to investigate the effectiveness of intraoperative antibiotic/antiseptic irrigation and immersion in prosthetic-based breast reconstruction.

Patients and Methods: A single-center prospectively designed retrospective study was performed in the breast reconstruction department in Tianjin Medical University Cancer Institute and Hospital. Women were eligible for inclusion if they received prosthetic-based immediate or delayed breast reconstruction with or without bio-prosthetic matrix or synthetic mesh. Intravenous prophylactic cephazolin was administered 30 minutes prior to the operation, an additional bolus of intravenous cephazolin was administered at 3 hours after startup. Patients were excluded if preventative intravenous or oral antibiotics were given postop upon no suspicion or proof of infection. Three treatment groups were assigned for intraoperative antibiotic/antiseptic intervention. In group A, breast prosthetic was immersed with saline only, and breast pocket was irrigated with 10% povidone-iodine (PVI) followed by saline. In group B, breast prosthetic was immersed with cephazolin for 10 min and breast pocket was irrigated with 10% PVI followed by saline. In group C, breast prosthetic was immersed with cephazolin and breast pocket was irrigated with 10% PVI followed by cephazolin and afterwards saline. Clindamycin was used if patients were allergic to cephazolin. The primary outcome was SSI within 6 months post-op, and capsular contracture at least 12 months post-op. Breast-Q satisfaction questionnaires were regularly collected at 12-months post-op follow-up. Regression analysis was performed to identify risk factors associated with SSI.

Results: From August 2018 to November 2021, 324 patients were included in the study (108 in each group). Patient demographics and treatment variables were not significantly different among the groups. The total complications were similar in each treatment group (23.1% vs. 18.5% vs. 25.0%, P=0.5). The occurrence of SSI was 8.3% (9/108), 6.5% (7/108), and 8.3% (9/108) in group A, B and C, respectively, and no significant difference was noted (P=0.83). Prosthetic explantation rate was also similar ( 1.9% vs. 0.0% vs. 4.6%, P=0.07). The rate of capsular contracture showed a higher percentage in group A, but the difference didn't reach significant level (10.4% vs. 4.6% vs. 8.7%, P=0.27). Breast-Q Questionnaire follow-up at 12-month post-op did not differ regarding patient reported satisfaction with implant and with breast. Multivariate analysis showed age, neoadjuvant chemotherapy, specific surgeon and mastectomy flap necrosis were risk factors associated with significant occurrence of surgical site infection.

Conclusion: Pocket irrigation with 10%PVI followed by saline was adequate in preventing SSI. Adding single cephazolin in prosthetic immersion might provide benefits in reducing the long-term capsular contracture. Patients with higher age and history of neoadjuvant chemotherapy should be notified of increased chances of SSI, while compulsory surgeon's training in both mastectomy and reconstruction were advocated to reduce severe post-op complications.

Introduction: While infections in post-mastectomy breast reconstruction are prevalent and morbid, they remain poorly understood. Recently, with the evolution of microbiome science, studies have used 16S rRNA sequencing to examine and define the local breast microbiome, but this has not been investigated with respect to breast reconstruction and outcomes. Peri-expander fluid can be readily collected in patients with a dual port tissue expander, which could allow us to define the local microbiome at any given time point. This study aimed to determine the feasibility of obtaining microbiome data from peri-expander fluid.

Methods: We designed a pilot study including patients who were scheduled to undergo mastectomy with two-stage implant-based reconstruction using dual port tissue expanders. The peri-expander fluid was obtained by accessing the aspiration port during standard post-operative visits, and this fluid was stored in a 1:1 ratio with DNA/RNA shield at -20 degrees Celsius. The microbiome of each sample was defined using 16S rRNA microbiome sequencing.

Results: Five samples from four patients were sequenced to determine feasibility of obtaining microbiome data from the peri-expander aspirates. We were successful in obtaining microbiome data from all aspirates. Our results indicate that there are a large range of genera represented, but four genera appear to be the most pervasive: Burkholderia, Staphylococcus, Pseudomonas, and Streptococcus.

Conclusion: It is feasible to perform microbiome sequencing of peri-expander aspirates to define the local environment. Rather than focusing on eliminating certain bacteria with antibiotics, it may be more impactful to optimize the balance of the breast microbiome.

Introduction: Implant infections are a significant cause of morbidity after mastectomy with tissue expander placement, with reported infection rates ranging from 5.8% to 28%. Many plastic surgeons opt to give post-operative prophylactic antibiotics to these patients, however there is inconclusive data regarding whether this practice leads to reduced infection rates.

Methods: We designed a two-armed randomized-controlled trial in patients undergoing mastectomy with immediate tissue expander reconstruction. One cohort (24 hours) received standard pre-incision antibiotics and 24 hours of peri-operative antibiotics, while the other cohort (7 days) received the standard antibiotics and additionally seven days of post-operative antibiotics (cephalexin 500mg qid). Patients were followed for clinical signs of infection for at least ninety days. Data on infection rates and treatment types were collected and compared between cohorts.

Results: Thirty-nine patients were enrolled in the study. Twenty patients (32 breasts) were randomized to receive 24 hours of antibiotics, while 19 patients (32 breasts) were randomized to receive seven days of antibiotics. Five breasts in the 24 hours cohort had any infection (15.6%), compared to 11 breasts (34.4%) in the seven days cohort (p=0.083). All breasts that were treated with intravenous antibiotics ultimately required re-operation with tissue expander removal, including four breasts in the 24 hours cohort (12.5%), compared to eight breasts (25%) in the seven days cohort (p=0.200). Mean time from tissue expander placement to removal was 51.80+/-45.01 days in the 24 hours cohort, compared to 79.70+/-69.80 days in the seven days cohort (p=0.441).

Conclusion: Within our small pilot study, we found no significant differences in infection rates between groups of patients who received 24 hours compared to seven days of prophylactic antibiotics. Interestingly, rather than seeing a protective effect from a longer course of antibiotics, there was a trend toward increased infection rates and more delayed infections in the group of patients receiving seven days of prophylactic antibiotics.

Background: This study compared conventional and robot-assisted mastectomy and breast reconstruction. To the best of our knowledge, this is the first study that reports the results of robot-assisted mastectomy and breast reconstruction and compares the patient-reported outcomes. Method: A retrospective study included 473 breasts from 423 patients who underwent a conventional mastectomy and breast reconstruction and 164 breasts from 153 patients who underwent a robot-assisted mastectomy and breast reconstruction from July 2019 to October 2021. Demographic and oncologic data, reconstructive outcomes, and patient-reported outcomes (BREAST-Q) were evaluated. The results of implant-based and autologous breast reconstruction were separately evaluated. Results: Skin necrosis requiring surgical debridement was significantly higher in the conventional group (8.0%) than that in the robot-assisted group (2.0%) in implant-based reconstruction (p = 0.035). At 6–12 months, a greater sexual well-being score in implant-based reconstruction and a greater physical well-being score in autologous breast reconstruction was observed in patients who underwent robot-assisted breast reconstruction than in those who underwent conventional breast reconstruction in the BREAST-Q questionnaire. Conclusion: Robot-assisted mastectomy and breast reconstruction showed lower skin necrosis and better patient-reported outcomes (sexual well-being in implant, physical well-being in autologous). Therefore, this study found that robotic surgery could be a good option for mastectomy and breast reconstruction.  

Background: Commonly, patients reconstructed with tissue expanders immediately after mastectomy are admitted for monitoring after surgery. This approach offers direct post-operative monitoring and pain control, however, comes with unique risks such as hospital-acquired infection and psychosocial effects of admission. Same-day discharge may represent a reasonable approach in immediate breast reconstruction that could conserve resources, mitigate risk, and return the patient more quickly to their home environment to begin recovery.

Methods:
A retrospective review was conducted of patients who underwent tissue expander breast reconstruction between 2005 and 2019 identified in the NSQIP database. Patients were separated based on date of discharge. Demographic information, medical comorbidities, and outcomes were recorded. Statistical analysis was performed to identify factors associated with complications.

Results:
A total of 14,404 patients were included in this study, with 4538 bilateral and 9821 unilateral reconstructions. 1458 patients were discharged on the day of surgery (postoperative day 0), while 9,384 were discharged on postoperative day 1 and 3,562 were discharged on a later date. Discharge on postoperative day 2 was associated with unilateral reconstruction as well as more severe medical comorbidities. Approximately 11% of patients had a complication from surgery. The most common complication was reoperation, occurring in approximately 7% of patients. Readmission occurred in 5% and infection in 4%. Complications for patients who were discharged postoperative day 2 or later were significantly higher at 17% when compared to same-day discharge (6%) or next day discharge (9%). The rate of infection was similar between same and next day patients (3.1 v 3.6%) though it was significantly higher in patients discharged at postoperative day 2 or later (5%). Rates of readmission and reoperation were significantly lower in patients discharged same day (2% and 3%) when compared to next-day discharge (5% and 6%) and later discharge (7% and 11%). Factors besides day of discharge correlating with higher complication rates included hypertension, smoking, and diabetes.

Conclusions: Same-day discharge following tissue expander breast reconstruction was not associated with an increased risk of perioperative complications compared to next-day or later discharge. Though complications are higher in later-day discharge patients, this is likely confounding from prolonged hospital stays due to immediate complications, or due to their underlying medical complexity predisposing them to higher risk. For the otherwise healthy patient, discharge the day of surgery is a safe and cost effective option. Ultimately, the decision when to discharge should be discussed in the context of each individual case.

Introduction: The excessive growth of the breasts (currently known as macromastia) proposes a health problem in women.1 Symptoms, such as chronic upper/lower back pain, neck pain, intertrigo, paresthesias, grooves in bra slots, and inability to do sports, are predominant.2

Several techniques have been developed for breast reduction, the inferior pedicle and free nipple graft have been favored as the first option in cases of displacement of the NAC from the sternal notch (SN) of 40 cm or more, along with the need for large volume resection.3

This is due to the apparent risk of partial or total necrosis, venous congestion, conical shape, and the impossibility of ascending the NAC.4

This study's objective is to present a different technique for long NAC ascending in patients with macromastia using a total superior pedicle lifting approach from a vertical marking with horizontal modification, without injuring the dermis around the NAC.

Methods: A single-center descriptive study was performed in Santiago de los Caballeros, Dominican Republic, from 2006 to 2022. A total pedicle lifting technique from a vertical marking with horizontal modification was performed on approximately 283 patients where 232 had a resection greater than or equal to 500 grams in one or both breasts with NAC descending lengths greater than 30cm.

Results: All cases were resolved without presenting tissue damage or NAC necrosis. The average patient's age was 34.5, and surgery time was approximately 3 hours. Considering both breasts, the average tissue extracted in the population was 1441.4+589.6 grams (SD, 95 %) with a median of 121 1.5 grams

Conclusions: The total pedicle lifting approach is a safe and reproducible procedure, distinguished by the regard for the upper circulation of the breast.

1. Escobar, R, Merelo, C. (2023). Breast Reduction with Total Superior Pedicle. Plast Reconstr Surg Glob Open, 11. https://doi.org/10.1097/GOX.0000000000004735
2. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. 1997;100:875–883.
3. Hoppe IC, Patel PP, Singer-Granick CJ, et al. Virginal mammary hypertrophy: a meta-analysis and treatment algorithm. Plast Reconstr Surg. 2011;127:2224–2231.
4. Colohan SM, Massenburg BB, Gougoutas AJ. Breast reduction: surgical techniques with an emphasis on evidence-based practice and outcomes. Plast Reconstr Surg. 2020;146:339e–350e.
5. Cruz-Korchin N, Korchin L. Vertical versus wise pattern breast reduction: patient satisfaction, revision rates, and complications. Plast Reconstr Surg. 2003;112:1573–1578.

Background: Vascularity of the nipple-areolar complex (NAC) is altered after reduction mammoplasty, which increases the risk of complications after repeat reduction mammoplasty or nipple-sparing mastectomy. Objectives: To evaluate angiogenesis of the NAC via serial analysis of breast magnetic resonance images (MRIs). Methods: Breast MRIs obtained after reduction mammoplasty were analyzed for 35 patients (39 breasts) using three-dimensional reconstructions of maximal intensity projection images. All veins terminating at the NAC were classified as internal mammary, anterior intercostal, or lateral thoracic in origin. The vein with the largest diameter was considered the dominant vein. Images were classified based on the time since reduction: <6 months, 6–12 months, 12–24 months, >2 years. Results: The average number of veins increased over time: 1.17 (<6 months), 1.56 (6–12 months), 1.64 (12–24 months), 1.73 (>2 years). Within 6 months, the pedicle was the only visible source of venous drainage. Veins from other sources began to appear at 6–12 months. In most patients, at least two veins were available after 1 year. After 1 year, the internal mammary vein was the most common dominant vein regardless of the pedicle used. Conclusion: In the initial 6 months after reduction mammoplasty, the pedicle is the only source of venous drainage; however, additional sources are available after 1 year and internal thoracic vessels were the dominant source in most of the patients. Thus, repeat reduction mammoplasty or nipple-sparing mastectomy should be performed ≥1 year following the initial procedure. After 1 year, the superior or superomedial pedicle may represent the safest option when the previous pedicle is unknown.

1. Serletti JM, Reading G, Caldwell E, Wray RC. Long-term patient satisfaction following reduction mammoplasty. Ann Plast Surg. 1992;28(4):363–365. doi:10.1097/00000637-199204000-00011
2. Gonzalez MA, Glickman LT, Aladegbami B, Simpson RL. Quality of life after breast reduction surgery: A 10-year retrospective analysis using the breast Q questionnaire: Does breast size matter? Ann Plast Surg. 2012;69(4):361–363. doi:10.1097/SAP.0b013e31824a218a
3. Hallock GG, Cusenz BJ. Salvage of the congested nipple during reduction mammoplasty. Aesthet Plast Surg. 1986;10(1):143–145. doi:10.1007/BF01575284
4. Erba P, Rieger UM, Pierer G, Kalbermatten DF. Vacuum-assisted closure (VAC) for venous congestion of the nipple-areola complex. J Plast Reconstr Aesthet Surg. 2008;61(7):852–854. doi:10.1016/j.bjps.2007.10.080
5. Park JK, Myung Y. Treatment of delayed venous congestion of the nipple-areolar complex after reduction mammoplasty. Arch Aesthet Plast Surg. 2021;27(1):39–42. doi:10.14730/aaps.2020.02369

Background: Plastic surgery has expanded to include the use of robotic surgery as a useful adjunct in breast reconstructive surgery. In a traditional deep inferior epigastric perforator (DIEP) flap harvest for breast reconstruction, a long fascial incision is required, which can lead to considerable donor site morbidity. With a robotic approach, the vascular pedicle can be dissected in the sub-muscular plane, through an intra-abdominal approach, thereby significantly reducing the length of the fascial incision. A shorter fascial dissection should decrease the rates of post-operative abdominal site morbidity and lead to improved patient outcomes. The authors assess the safety, feasibility, and efficiency of robotic-assisted DIEP flaps.

Methods: All consecutive cases of robotic-assisted DIEP flaps for breast reconstruction from June 2022 to February 2023 within a single health care system (Northwell Health) were reviewed. Patient demographics, surgical characteristics, and complications were assessed. The authors also provided insight regarding the training, credentialing, and implementation of a robotic breast program.

Results: A total of 17 female patients underwent robotic-assisted DIEP harvest. Mean patient age at time of surgery was 50.1 years and mean BMI was 26.4 kg/m2. Of 17 patients, 10/17 were bilateral and 2/17 were unilateral robotic-assisted DIEP flap breast reconstructions. The remaining 5/17 were bilateral DIEP flap reconstructions but vascular anatomy allowed for only one hemi-abdominal flap harvest to be performed with robotic assistance. A total of 8/17 were performed immediately at the time of mastectomy. All patients had preoperative magnetic resonance angiography (MRA). Mean length of fascial incision was 3.7 cm. Mean time on the robotic console was 75.1 minutes. Mean length of hospital stay was 2.2 days. All flaps were harvested with robotic assistance, without conversion to open technique. No abdominal donor site postoperative complications were noted, including abdominal wall bulge, hernia, necrosis, or delayed healing.

Conclusion: In appropriately selected candidates, robotic-assisted harvest of the deep inferior epigastric perforator flap is a safe, reliable, and reproducible technique to attempt at decreasing rates of abdominal donor site morbidity

Introduction: Breast reconstruction is an important component of breast cancer treatment and recovery. However, disparities exist in the availability and accessibility of healthcare providers and institutions that offer reconstructive services. Past studies have characterized how race, ethnicity, socioeconomic status, insurance policy, and other demographic factors may individually influence access to reconstruction. The Area of Deprivation Index (ADI) is a composite measure that includes data on income, employment, health, education, and crime rates.(1) This value enables policymakers to assess the extent of socioeconomic deprivation within small geographic regions and identify areas that require targeted resource allocation.1 Our objective is to examine the correlation between ADI and the proportion of patients who undergo post-mastectomy reconstruction, as well as the length of time it takes for them to receive treatment. In addition, we aim to assess the utility of ADI as a surrogate for predicting access to reconstructive services.

Methods: Retrospective review identified post-mastectomy patients at NYP-Cornell and Columbia between 1979 and 2019. The list of ADIs for New York City zones are obtained from the Center for Health Disparities Research website. Composite reconstruction rates and average time delay to reconstruction are calculated for each zip code within the NYP breast cancer database and matched with the corresponding district ADI. In general, higher ADI corresponds to increased resource deprivation. Pearson correlation formula is used to assess the dependency of the two measures. Python is used to plot the heatmaps showcasing the proportion of reconstruction, relative time lag, and ADI.

Results: We found a negative correlation between the likelihood of undergoing reconstruction and the ADI of the patient's residential district (R = - 0.081), and a positive correlation between the time delay to reconstruction and increased ADI (R = 0.065). The heatmap distribution corroborates the quantitative trends we observed on correlation analysis.

Conclusion: The Area of Deprivation Index may provide a preliminary indication of the accessibility of reconstructive services and the expected delay in physician consultation. To address disparities in post-mastectomy breast reconstruction, it is imperative to enhance patient awareness and education, particularly in regions with higher levels of socioeconomic deprivation. Legislative and patient advocacy initiatives should especially focus on areas facing geographic or financial limitations. Additionally, the ADI can aid in monitoring resource allocation and assessing the effectiveness of interventions aimed at promoting equitable access to breast reconstruction.

References 1. Noble, M., Wright, G., Smith, G., & Dibben, C. (2006). Measuring Multiple Deprivation at the Small-Area Level. Environment and Planning A: Economy and Space, 38(1), 169–185. https://doi.org/10.1068/a37168

Background: Breast reconstruction using endoscopy-assisted latissimus dorsi (LD) flap leaves no scar on the back; however, the small amount of tissue obtained makes this procedure less practical1-4. This study aimed to propose and show a new technique of endoscopy-assisted extended LD (eeLD) flap plus lipofilling, which could secure a large breast volume. Methods: Lateral thoracic adipose tissues supplied by the thoracodorsal artery branches and the LD muscle were elevated as a single unit only through the mastectomy scar and three ports through the lateral chest5. Further, fat was simultaneously injected to support the volume and shape of the breast. Changes in the volume of the reconstructed breast over time were measured using three-dimensional stereophotogrammetry. Results: Overall, 15 breasts of 14 patients who underwent breast reconstruction using an eeLD flap exhibited no serious complications. On average, 281.9 ± 32.4 g of flap and 74.7 ± 19.4 ml of lipofilling were used. Within 8 weeks after the procedure, the volume of the reconstructed breast decreased to 69.5% ± 7.5% and then plateaued. Seven patients needed a subsequent session of lipofilling to acquire adequate breast volume and projection. Notably, according to the BREAST-Q back scores, patients who underwent eeLD flap were significantly more satisfied than those who underwent conventional LD musculocutaneous flap using a skin paddle on the back at the same institution (82.8 ± 9.2 vs. 62.6 ± 6.3, P < 0.0001). Conclusion: Despite the limitations in volume, eeLD flap plus lipofilling is advantageous because it does not leave a noticeable donor site scar.   References 1. Escandón JM, Nazerali R, Ciudad P, et al. Minimally invasive harvest of the latissimus dorsi flap for breast reconstruction: A systematic review. Int J Med Robot. 2022;18:e2446. 2. Cha Y, Lee S. Endoscopy-assisted latissimus dorsi muscle flap harvesting technique for immediate breast reconstruction. Ann Chir Plast Esthet. 2022. S0294-1260(22)00171-6. 3. Ahmed YS, Abd El Maksoud WM. Combined Endoscopy-Assisted Muscle-Sparing Latissimus Dorsi Flap Harvesting with Lipofilling Enhancement as a New Volume Replacement Technique in Breast Reconstruction. Breast J. 2022;7740439. 4. Winocour S, Tarassoli S, Chu CK, et al. Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction. Liu J, Clemens MW, Selber JC. Plast Reconstr Surg. 2020; 146: 1221-12258.
5. Dast S, Havet E, Dessena L, et al. Anatomical basis of the extended TDAP flap: study of its territories of vascularization and its volume. Surg Radiol Anat. 2017; 39: 821-826.

Purpose: to create the optimal algorithm of treatment of late seroma formation in breast revisional surgery

Methods: Since December 2018 to October 2022 in Sechenov University clinic in Moscow, Russia 78 patients were diagnosed with late seroma formation after pervious breast augmentation procedure. The diagnostic algorithm included clinical evaluation of symptoms, magnetic resonance imaging with contrast, punction of seroma with ultrasound assistance, flow cytometry, immunohistochemistry performed for aspirated fluid. Surgical correction was performed after the diagnostic algorithm completed.

Results: in 88.5% of cases (69 out of 78) unilateral seroma formation were discovered. All serums were defined as a late because their manifestation time was later than one year (from 1 year and a month to 18 years and 7 months). The etiology of seroma formation in most cases (73 of 78) was idiopathic, in 5 cases different kind of foreign bodies were discovered in the pocket of implants. Not a single capsular mass formation was discovered in this clinical seria. Most of the implants removed were textured (75 of 78), in 2 cases implants were silicone round with smooth surface and in one saline round with smooth surface. Beside for seroma symptoms most of the patients complained about various kind breast asymmetry, unsatisfactory breast shape, unpleasant areola size or nipple position, cleavage problems. Thus, the aesthetic goals were considered with correction of the late seroma. Correction of the late seroma and aesthetic improvement was performed as a one stage procedure, in most cases including implants replacement, capsulectomy, different kind of mastopexy, fat grafting.

Conclusion: Most of the patients with late seroma require simultaneous aesthetic correction. The diagnostic algorithm is applied in every case of late seroma to avoid rare and potentially malignant etiology of this complication. When diagnostic is complete, the simultaneous aesthetic correction is planned based on patient's complaints and aesthetic distortions present. Secondary correction often requires correction of the asymmetry. Old capsule on the seroma side should be removed to avoid seroma recurrence. Asymmetry was the most common aesthetic complaint of the patients in this group. Correction of the asymmetry was performed with simultaneous mastopexy, fatgrafting, different volume implants was applied.

INTRODUCTION Direct-to-implant (DTI) breast reconstruction is a reasonable alternative to two-stage reconstruction for patients who desire aesthetic benefits, minimal morbidity, and a single-stage operation. However, Complications including infection and wound dehiscence are major concerns for DTI breast reconstruction. Therefore, we aimed to identify the risk factors associated with severe complications following DTI breast reconstruction and introduce an evidence-based algorithm for complication prevention and implant salvage.

METHODS A retrospective study was performed using Tianjin Implant-based Breast Reconstruction (TIMBRE) cohort (Registration No.: ChiCTR2000035318), a prospectively maintained database of all female patients undergoing implant-based breast reconstruction at the largest breast cancer center in China. Women who underwent single-stage unilateral DTI breast reconstruction from January 1, 2014, to December 31, 2022, were included. A "severe" complication was defined as unplanned complications requiring re-hospitalization or re-operation. All complications occurring within 90 days of surgery were recorded to avoid underreporting. The risk factors associated with complications and prosthesis explantation were identified using multivariate logistic regression modeling and interaction analyses. A comparison of implant salvage rate was made between the regional perforator flap maneuver and non-flap methods.

RESULTS Among 1027 patients enrolled, 90 experienced severe complications, 41 of which underwent prosthesis explantation, while 49 were successfully salvaged. Multivariate analysis demonstrated that patients with larger implant size (p=0.003), use of biological meshes (p<0.001), adjuvant radiotherapy (p=0.047), low plasma albumin (p=0.013), and elevated blood glucose (p=0.006) were significantly more likely to suffer complications. Adjuvant radiation (OR: 7.44; 95%CI, 1.49-37.18; p=0.014) and obesity (OR, 4.17; 95%CI, 1.17-14.88; p = 0.028) had significantly lower rates of implant salvage as well as surgical site infection (SSI) and wound dehiscence, while mastectomy skin flap necrosis was not associated with device explanation. There were no differences in complication and explantation rates between nipple-sparing and skin-sparing mastectomies. SSI and wound dehiscence were the primary factors associated with implant loss in DTIBR. Subgroup analysis indicated the combined impact of SSI and wound dehiscence added over fourteen-fold high risk of prosthesis explantation (Figure 1, relative excess risk of interaction, 14.75, 95%CI, 9.97-19.53). Regarding the patients with uninfected wound dehiscence or mastectomy flap necrosis, the regional perforator flap transfer successfully salvaged 100% of breast implants (Figure 2, n=12). The rate of prosthesis salvage was significantly higher in flap group compared with the cases undergoing non-flap management (p=0.035).

CONCLUSION Loss of an implant in direct-to-implant breast reconstruction is multifactorial. Larger implant size, adjuvant radiation therapy, diabetes, and malnutrition should be considered contraindications to the DTI approach. The combination of surgical site infection and wound dehiscence has a synergistic negative impact on reconstructive failure and portends a dismal outcome for implant salvage. Avoiding infection and restoring the skin defect by a vascularized perforator flap can limit the risks of reconstructive failure in patients suffering from wound dehiscence.

Purpose: Intraoperative hypothermia has been studied and demonstrated to be a risk factor for impaired wound healing, increased hospital length of stay, and surgical site infection in other surgical specialties.1,2 Intraoperative hypothermia represents a potential modifiable risk factor in breast reduction surgery. This study examines the effect of intraoperative hypothermia on postoperative outcomes in breast reduction surgery.

Methods: This was a retrospective review of consecutive patients undergoing bilateral breast reduction from 2015 to 2021. Patients were categorized into normothermic and hypothermic cohorts based on intraoperative measurements of core temperature, and hypothermia was defined as <35.5°C. Demographics, comorbidities, smoking status, ASA class, intraoperative warming devices, duration of hypothermia, type of pedicle used, weight of surgical specimens, surgical drains, and length of surgery were collected. The outcomes assessed were infection within 30 days, wound healing complications, hematoma, and seroma.

Results: In the study population of 142 consecutive patients, 85 experienced intraoperative hypothermia and 57 were normothermic throughout surgery. The average age was 40.25, average BMI 31.65, 12.7% had Type 1 or Type 2 Diabetes, and 4.9% were current smokers. 73.9% (105) of patients underwent bilateral breast reduction with a superomedial pedicle, 22.5% (32) had an inferior pedicle, and 3.5% (5) had another type of pedicle. Over half (59.9%) of patients experienced intraoperative hypothermia. In the hypothermic group, a higher proportion of patients had surgical site infections (18.8% versus 5.3%, p<0.05) and wound healing complications (61.2% versus 29.8%, p<0.05). Both groups had similar incidence of postoperative seroma (2% versus 0%) and hematoma (5.9% versus 3.5%). Further analysis demonstrated, intraoperative hypothermia predicted surgical site infection (OR 4.174, 95% CI: 1.156-15.064, p<0.05) and wound healing complications (OR 3.708, 95% CI: 1.812-7.585, p<0.05).

Conclusion: This study demonstrates that intraoperative hypothermia is a significant risk factor for postoperative infection and wound healing complications in breast reduction. Our results demonstrate that maintaining strict normothermia during breast reduction can improve patient outcomes by reducing the risk of postoperative infection and wound healing complications

References: 1. Baucom RB, Phillips SE, Ehrenfeld JM, et al. Association of Perioperative Hypothermia During Colectomy With Surgical Site Infection. JAMA Surg. 2015;150(6):570-575. doi:10.1001/jamasurg.2015.77 2. Seamon MJ, Wobb J, Gaughan JP, Kulp H, Kamel I, Dempsey DT. The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies. Ann Surg. 2012;255(4):789-795. doi:10.1097/SLA.0b013e31824b7e35

Purpose: Seroma formation is a common complication following postmastectomy breast reconstruction. Often, seroma formation begets other complications such as infection, which can compromise the reconstruction. In this study, we investigated the association between seroma formation and other complications following prepectoral tissue expander (TE) reconstruction. Methods: All consecutive, prepectoral TE reconstructions performed between March 2017 and July 2022 at a single center were reviewed. Patients were cared for by five distinct breast surgeons and five plastic surgeons. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. A p<0.05 was considered statistically significant. Results: Prepectoral TE reconstruction was performed in 184 patients (292 breasts), who were followed for an average of 27 months. Women were, on average, 53 years old, non-smoker (99%), non-diabetic (91%), and had a body mass index (BMI) of 28. 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% prior radiation, 1% both). Median mastectomy weight was 551 grams, average intraoperative TE fill was 194 ± 163 cc, and average final TE fill was 416 ± 159 cc. Seroma occurred in 45 (15%) breasts and was associated with higher body mass index (30 vs. 27 kg/m2, p=0.011) and higher mastectomy weight (814 vs. 640 grams, p < 0.05). In multivariable models controlling for age, BMI, mastectomy weight, radiation, and soft tissue support, seroma was not associated with any predictive variables.
Seroma was associated with postoperative infection (42% vs. 7%, p < 0.001), TE exposure (50% vs. 8%, p <0.05), and explantation (51% vs. 9%, p < 0.001). A temporal association was seen between seroma occurrence and the incidence of other complications: 25 (56%) seromas went on to develop other complications. Infection and implant explantation commonly followed seroma, occurring in 16 (36%) and 15 (33%) breasts with a prior seroma, respectively. These infections were managed successfully with antibiotics in 7 (44%) of breasts, but 9 (56%) required further surgical intervention, such as implant explantation or exchange. Conclusions: This study examines the connection between seroma and other postoperative complications. Although causality cannot be determined, the data support the hypothesis of seroma being the "kiss of death" in patients undergoing prepectoral TE reconstruction, as over half of patients who developed a seroma went on to develop other related complications.

Background: A well-known post-operative complication of mastectomy with axillary lymph node dissection (ALND) with immediate implant-based breast reconstruction (IBR) is lymphedema of the upper extremity, or Breast-Cancer Related Lymphedema (BCRL). Standard practices include staging LVA at later date versus treatment only if patient becomes symptomatic. The aim of our study is to assess the trends, feasibility, and safety of prophylactic lymphovenous anastomosis (LVA) at time of index mastectomy, ALND, and IBR.

Methods: The 2015-2020 NSQIP database was reviewed to identify patients who underwent mastectomy, ALND, and IBR using pre-defined CPT codes for aforementioned procedures. Cohorts were separated into a treatment group, those who underwent mastectomy + ALND + IBR + LVA at the time of index operation, and a control group, those who underwent mastectomy + ALND + IBR alone. Patient demographics, comorbidities, surgical characteristics, and reconstruction type as well as 30-day complication rates, length of stay, and readmission/reoperation rates were collected and analyzed.

Results: The NSQIP database identified 25,888 patients who underwent mastectomy and ALND with immediate IBR; of these, 151 prophylactic LVA's were performed the time of initial surgery (0.58%). Average age and BMI amongst treatment and control groups were 48.1  11.2 years and 28.2  6.4 kg/m2, and 50.7  10.8 years and 27.9  6.0 kg/m2, respectively. No significant differences were found amongst demographics or surgical characteristics between treatment and control groups. As expected, average operative times were longer with concomitant LVA (363 min vs 262 min, p-value <0.001). The most common complications amongst both treatment and control groups were superficial SSI (3.31%, 2.42% respectively), deep SSI (3.31%, 1.99% respectively), and wound dehiscence (2.65%, 1.12% respectively). Post operative length of stay was similar between groups at 1.7  3.2 days for control group and 1.8  1.4 days in treatment group (p-value 0.75). While readmission rates were slightly higher for the LVA group (7.28% versus 5.24%), this was not statistically significant and reoperation rates were slightly decreased compared to the control group at 7.95% and 8.56%, respectively.

Conclusion: The results of this study suggest that immediate LVA at time of index surgery is safe and feasible in the setting of mastectomy, ALNB, and immediate IBR without significant impact on complication profile, hospital length of stay, reoperation, or readmission. Limitations include low sample size of treatment group and the ability of NSQIP database to drive clinically insignificant variables to significance. Given the nature of NSQIP database, we were unable to elucidate the effectiveness of immediate LVA at prevention of BCAL however this will be a focus in future studies.

Purpose: While many factors in prepectoral breast reconstruction such as mastectomy weight and flap quality are out of the plastic surgeon's control, some factors such as intraoperative tissue expander (TE) fill can be optimized. This study analyzes the impact of intraoperative TE fill on postoperative complications and attempts to define an optimal fill volume. Methods: A chart review of all consecutive, prepectoral tissue expander reconstructions performed between March 2017 and July 2022 at a single center was conducted. Patients from a total of 5 distinct breast surgeons and 5 plastic surgeons were included. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. A ratio of intraoperative TE fill to mastectomy weight (TEF/MW) was constructed to quantify "deadspace" in the breast pocket, with higher values signifying less deadspace. Major complications were defined as any complication that required readmission or reoperation while minor complications included any complication requiring outpatient antibiotics, procedures, or wound care. The Youden method was used for predicting optimal cut off, and p<0.05 was considered statistically significant. Results: A total of 184 patients (292 breasts) were included with a mean follow up period of 27 months. Patients were on average 53 years old, non-smoker (99%), non-diabetic (91%), and had a body mass index of 28. Immediate reconstructions were performed 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). Median mastectomy weight was 551 grams, average intraoperative TE fill was 194 ± 163 cc, and average final TE fill was 416 ± 159 cc. Major complications occurred in 61 (21%) breasts and were associated with higher intraoperative TE fill (277 cc vs. 174 cc, p <0.001) and less deadspace in the breast pocket (0.49 TEF/MW vs. 0.37 TEF/MW, p <0.05). In multivariable models controlling for age, BMI, diabetes, mastectomy weight, radiation, and soft tissue support, higher odds of major complication were observed: for every 10 cc increase in intraoperative TE fill, the odds increased by 1.03 (95% CI [1.01-1.05], p=0.002). Optimal intraoperative TE fill for avoiding major complications was 80 cc and optimal ratio was 0.09 TEF/MW. Among major complications, explantation occurred in 44 (15%) breasts and was associated with higher intraoperative TE fill (271 cc vs. 182 cc, p <0.001) and less deadspace in the breast pocket (0.51 TEF/MW vs. 0.37 TEF/MW, p <0.001). Optimal intraoperative TE fill for avoiding explantation was 80 cc and optimal ratio was 0.12 TEF/MW. TE exchange occurred in 19 (7%) breasts and was associated with higher intraoperative TE fill (349 cc vs. 185 cc, p <0.001) and less deadspace in the breast pocket (0.7 TEF/MW vs. 0.37 TEF/MW, p <0.05).
Conclusions: In this study, higher intraoperative TE fill and less deadspace was associated with major postoperative complications, explantation, and need for TE exchange.

Background: Over 97,000 reduction mammaplasties were performed in the US exceeding all other body-contouring procedures combined. Several studies have suggested no significant difference in complications with or without intraoperative placement of drains but have been inadequately powered to assess individual outcomes such as seromas or wound dehiscence1-3. We aimed to assess whether use of drains was associated with a lower risk of complications after breast reduction in a multi-institutional cohort study. Methods: A retrospective cohort of 2488 breast reduction patients with and without drains was evaluated across five institutions. Demographic and peri-operative data were compared between groups. Univariate analysis of post-operative outcomes was performed and multivariate logistic regression of the impact of intra-operative drain placement and patient factors were evaluated. Results: Drains were used in 1163 patients (46.7%) and 1325 (53.3%) were performed without drains. Patient with higher BMI (p<0.001), greater pre-operative breast anthropometrics (p<0.001), higher mean resection weight (p<0.001) multiple medical comorbidities (p<0.05) and superior dermo-glandular pedicle (p<0.001) were less likely to have drains placed for surgery. The drain cohort were also more likely to have liposuction or other concomitant procedures and free nipple grafting (p<0.05). Despite these preoperative differences in the drain cohort, there was no significant difference in overall complication rate (30.7% vs 27.1%), wound dehiscence (12.3% vs 14.2%), seroma (1.8% vs 2.0%), hematoma (2.9 vs 3.7%), infection (9.7% vs 7.8%) or need for revision surgery (11% vs 10.2%). Drains were not significantly associated with any complications on logistic regression, but elevated BMI was significantly associated with overall complications, seroma and wound dehiscence (all p<0.01) while hematologic disease and black race were also associated with seroma (p<0.01). Summary: Drain placement was not associated with improved outcomes after breast reduction surgery in a large multi-center retrospective cohort. Surgeons were more likely to use drains in patients with higher BMI, larger breasts and higher medical complexity with similar outcomes to the cohort without drains. Elevated BMI was the consistently associated with surgical complications.

1.Corion LU, Smeulders MJ, van Zuijlen PP, van der Horst CM. Draining after breast reduction: A randomised controlled inter-patient study. J Plast Reconstr Aesthet Surg. 2009;62:865–868. 2. Collis N, McGuiness CM, Batchelor AG. Drainage in breast reduction surgery: A prospective randomised intra-patient trial. Br J Plast Surg. 2005;58:286–289. 3. Wrye SW, Banducci DR, Mackay D, Graham WP, Hall WW. Routine drainage is not required in reduction mammaplasty. Plast Reconstr Surg. 2003;111:113–117.

Background: Recent discussions in medical billing have raised concerns about the potential loss of insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction by December 31, 2024. These changes may require patients to pay out-of-pocket for this procedure. This survey aims to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes.

Methods: A survey was conducted among adult women in the United States via the Amazon Mechanical Turk crowdsourcing platform. Questions assessed demographic information and gauged patient preferences for breast reconstructive options, ultimately asking participants to choose between descriptions of DIEP and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test was used to assess trends in flap preferences with incremental increases in out-of-pocket payments.

Results: Of 500 total responses, 485 were complete and correctly answered a question to verify adequate attention to the survey questions. The median (IQR) age of respondents was 26 (25, 39) years old. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP flap reconstruction. When presented with the same choice, however with DIEP flaps being associated with an incrementally rising cost, an increasing proportion of the respondents favored the cheaper TRAM option with $10,000 out of pocket being the threshold where a majority of women who previously favored DIEP, changed their answer to TRAM (p < 0.001). Notably, a personal history of breast reconstruction was significantly associated with a higher preference for DIEP, even with an associated out-of-pocket cost of $10,000 (p = 0.04). Additionally, respondents' education histories also affected preference for DIEP flaps. A significantly higher proportion of high school graduates (26%) preferred DIEP even with a $20,000 out-of-pocket payment compared to respondents with a bachelor's degree (3%) (p = 0.003).

Conclusion: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reconsideration of newly proposed insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to gold standard reconstructive options.

Background. BioZorb® three-dimensional bioabsorbable tissue marker was developed as a tool for radiotherapy to provide more consistent and accurate identification for surgical margins and more precise radiation fields in patients with breast cancer pursuing breast-conserving surgery (BCS). In women with small to medium breast volume, BCS can be challenging due to limited reconstructive options, often resulting in contour abnormalities and breast asymmetry due to the limited availability of breast tissue for sufficient local tissue rearrangement. The BioZorb® device allows for simultaneous volume displacement and replacement in the setting of BCS, which affords an added benefit of maintaining breast contour and symmetry.

Methods. One hundred and nineteen women received the BioZorb® device following BCS between January 2016 to December 2020. Patient reported outcomes (PROs) were obtained from women ages 18 or older using the validated Breast-Q questionnaire. Outcomes focused on physical wellbeing, satisfaction with breasts, psychosocial wellbeing, and sexual wellbeing. Rasch analysis was used to generate a numerical score (maximum=100) for data analysis.

Results. Of the 119 women, 32 completed surveys for PROs. 90.6% of these women had a bra cup size of D or less and received a Biozorb® implant ranging in size from 2x2 cm to 4x4 cm. Of the 32 women, no patients had post-operative infection or required implant removal within 30 days of surgery. Breast-Q questionnaires demonstrated an average Rasch score of 83.2 for physical well-being, 78.2 for satisfaction with breasts, and 86.7 for psychosocial wellbeing. 40.6% of participants completed the sexual wellbeing section with an average score of 69.5. Breast size stratification demonstrated that for women with smaller breasts (Cup size A or B) Rasch score was 80.1 for physical wellbeing, 78.8 for satisfaction with breasts, and 84.2 for psychosocial wellbeing. In women with larger breasts (Cup size C or larger), Rasch score was 87.5 for physical wellbeing, 77.2 for satisfaction with breasts, and 89.9 for psychosocial wellbeing.

Conclusions. Based on PROs using the Breast-Q questionnaire, women who underwent BCS with Biozorb® placement not only benefitted from its ability to provide a marker for radiation, but were also content with their surgical outcomes, reporting excellent physical and psychosocial health, as well as breast satisfaction. Additionally, women with smaller breasts reported equally excellent outcomes compared to those women with medium or larger breasts. Based on the outcomes from this study, simultaneous volume displacement and replacement using the Biozorb® device in women with smaller breasts can result in favorable PROs.