Scientific Abstract Presentations: Breast 11 Sunday, October 29 Sun, Oct 29 4:00-5:00 p.m. CDT

Purpose:
Nearly 300,000 women/year are diagnosed with breast cancer in the US.1 Mastectomy and radiation are the standard treatment for high-risk disease.2 In 3D computer-tomography (3DCT) radiation, the lungs/heart are difficult to protect. Radiation has been shown to cause dose-dependent changes in the lungs and heart.3 Few studies have investigated the effect of tissue expanders (TE) on radiation dose to the heart and lungs.4 We investigated the differences in post-mastectomy radiation therapy (PMRT) doses to these organs at risk (OARs) in patients with mastectomy only versus immediate reconstruction with a TE.

Methods: Using the ARIA© oncology database, retrospective analysis identified all women with breast cancer who underwent total mastectomy and completed a full course of PMRT with 3DCT between January 2005 and August 2022 at our institution. They were then divided into mastectomy versus mastecomy+TE. Demographics, BMI, mastectomy side, tumor size, lymph node involvement, chemotherapy status, PRMT boost and bolus use were collected. TE intraoperative fill volume was obtained and dichotomized ≤60cc versus >60cc. Using Wilcoxon rank sum tests, dose statistics for ipsilateral lung and heart were compared between mastectomy versus mastectomy+TE and dose statistics were compared between the dichotomized TE intraoperative fill volumes. Bivariate correlations between dose statistics and BMI were analyzed using Spearman correlation.

Results: 124 women met inclusion criteria (mastectomy n=66 versus mastecomy+TE n=58). 21 women had a TE fill volume ≤60cc versus 35 women had >60cc. No significant differences were observed in lung or heart radiotherapy across all dose metrics between patients who underwent mastectomy versus mastectomy+TE nor between patients with TE fill volume 60cc. Correlations between BMI and heart maximum dose (p = 0.03) were significantly different and showed a positive, mono-clonal correlation (correlation: 0.20, 95% Cl: 0.02, 0.37). Significant differences in bolus (p < 0.01) and age (p < 0.01) were observed between the two procedures. Bolus rate was higher for patients receiving mastectomy alone compared to mastectomy+TE (93.94% vs. 72.41%). Patients who underwent mastectomy alone were older compared to mastectomy+TE (Mean: 62.62 years vs. 48.19 years). In addition, significantly more patients who underwent a bilateral mastectomy subsequently underwent reconstruction (65.52% vs. 28.79%).

Conclusion: Overall, there were no differences in the radiation dose to the OARs in patients with mastectomy only vs. mastectomy+TE. Importantly, TE intraoperative expander fill did not affect dose distribution to the OARs.

References 1. Siegel, R. L., Miller, K. D., Wagle, N. S., & Jemal, A. (2023). Cancer statistics, 2023. CA: A Cancer Journal for Clinicians, 73(1), 17–48. 2. Remick J, Amin NP. Postmastectomy Breast Cancer Radiation Therapy. 2022 Jan 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 3. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368:987–998. 4. Liljegren A, Unukovych D, Gagliardi G, et al. No difference in dose distribution in organs at risk in postmastectomy radiotherapy with or without breast implant reconstruction. Radiat Oncol. 2014 Jan 9;9:14.

Introduction: Breast implant illness (BII) describes a constellation of systemic symptoms that patients report to be associated with their breast implants [1]. Social media platforms are increasingly being utilized as a medical resource; this is particularly true of TikTok (Culver City, CA, USA), which is an international popular video-sharing platform that has amassed 1.2 billion monthly active users in the third quarter of 2021 [2]. As BII is a largely patient-driven phenomenon, it is important to understand how patient's knowledge of it is influenced by social media. These platforms are increasingly being utilized as a medical resource for surgery, where patients seek insight on treatment options [3]. This study sought to evaluate the quality and popularity of TikTok videos about BII.

Methods: Two validated tools for health information, DISCERN and the Patient Education Materials Assessment Tool (PEMAT), were utilized to evaluate the quality of information regarding the topic of breast implant illness on TikTok. Higher scores on these scales indicate higher quality content. Thirteen items on the PEMAT are related to comprehension and understandability, and four are related to actionability. The search phrase "breast implant illness" was used to query and screen videos, which were then sorted based on relevance and view count. The first 100 videos that fulfilled inclusion criteria were independently graded by three reviewers. Video characteristics, including video link, account name, number of account subscribers, account type, date of upload, length of video, number of likes, number of comments, and the presence of overlying audio were collected from each video.

Results: Increased video duration, number of shares, and videos that were categorized as patient education on TikTok were all statistically significantly associated with a higher total DISCERN score (all p < 0.05). Increased video duration was also statistically significantly associated with a higher PEMAT actionability score (p < 0.001). Videos in the patient experience category scored higher on PEMAT understandability (p = 0.004). A higher total DISCERN score was statistically significantly associated with higher PEMAT actionability (p < 0.001). Videos in the self-promotion category had lower DISCERN and PEMAT understandability scores (p = 0.018).

Conclusion: Total DISCERN and PEMAT scores for videos regarding BII on TikTok are low. However, videos with a higher number of shares were found to have a higher overall quality, suggesting that higher quality content quality content may therefore have an increased likelihood of reaching a larger audience. Increased video length, discussion of a patient experience, and the presence of a provider are worth considering when developing high-quality online content for breast reconstruction and augmentation patients.

References 1. Magnusson MR, Cooter RD, Rakhorst H, McGuire PA, Adams WP, Jr., Deva AK. Breast Implant Illness: A Way Forward. Plast Reconstr Surg. Mar 2019;143(3S A Review of Breast Implant-Associated Anaplastic Large Cell Lymphoma):74S-81S. doi:10.1097/PRS.0000000000005573 2. IQBAL M. TikTok Revenue and Usage Statistics (2022). December 2022. https://www.businessofapps.com/data/tik-tok-statistics/ 3. Ward B, Ayyala HS, Zhang K, Manuskhani PA, Paskhover B, Lee ES. YouTube for Cosmetic Plastic Surgery: An Effective Patient Resource? Aesthet Surg J. Apr 14 2020;40(5):NP314-NP319. doi:10.1093/asj/sjz268

Background: Autologous breast reconstruction is continually evolving with focus on the ideal donor site. This study presents 108 consecutive simultaneous LAP flaps and a perforator classification system.

Methods: An IRB approved retrospective review of all LAP flaps was completed and appropriate data recorded. All simultaneous bilateral LAP flaps were included, and perforator patterns were assessed using CTA.

Results: Fifty-four patients (108 flaps) were included in the final review. Mean age was 50.7 and mean BMI was 26.6. Mean ischemia times for all flaps and grafts were 130 +/- 64.5 and 300.6 +/- 97.3 minutes, respectively. Pedicle lengths averaged 4.6 +/- 1.5 cm and composite graft lengths averaged 6.2 +/- 1.7 cm. Donor site complications consisted of seromas (10 patients, 19%), hematomas (six patients, 11%), procedural wounds (four patients, 8% ), and infections (two patients, 4%). Total flap loss rate was 2.8%. Perforators were classified into categories based on pedicle pattern, lumbar spine level, and clusters, all in relation to posterior iliac bone as seen per CTA. Vascular pedicle pattern types 1, 2, and 3 were seen in 44.7%, 46.4%, and 8.9% of patients respectively. Perforators were dissected at lumbar spine level L3 in 52.7% of patients, L4 in 45.5%, and L5 in 1.8%.

Conclusions: We present a CTA directed, anatomical perforator classification system to assist in pre-operative planning, guide in dissection and choosing composite graft suited best for particular perforator pattern or calibers. Simultaneous LAP flaps can be successfully performed with excellent outcomes in patients unsuitable for other flaps.

Background Breast reconstruction is a team-oriented experience requiring collaboration between a patient, breast surgeon, and plastic surgeon. In order to optimize both surgical outcomes and aesthetic results, incision patterns must be carefully planned. We aim to determine whether vertical or horizontal orientation of mastectomy incision is preferred in the general population as well as analyze corresponding complication profiles.

Methods A REDCap database was utilized to perform a retrospective review of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 – November 2022. Post-operative complications of the two groups were analyzed. Additionally, crowdsourcing was performed to assess aesthetic implications of horizontal and vertical incision patterns on post-operative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess for differences in scoring based on voter characteristics.

Results There were no significant differences in post-operative breast complications between patients with horizontal or vertical incisions when looking at wounds, infections, seromas, hematomas, fat necrosis, or overall complications (p > 0.05). Crowdsourcing showed that regardless of voter demographics, vertical incisions were preferred over horizontal incisions (p < 0.001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (p < 0.001).

Conclusion While there are no significant differences in complication profiles between vertical and horizontal incisions in mastectomy patients, vertical incision patterns are preferred aesthetically in the general population across all demographic populations.

Background Post mastectomy reconstruction is on the rise. Implant-based techniques constitute approximately 81% of all breast reconstruction procedures performed in the United States. Alloplastic reconstruction may be performed as direct-to-implant (DTI) or, more commonly, as a two-staged reconstruction (TSR). While rigorous studies have explored the postoperative complication rates between DTI or TSR,1 little to none have stratified these outcomes by relevant populations, pre-operative physical exam findings, mastectomy characteristics, or plane of implant placement. Therefore, we sought to examine and compare the outcomes between these cohorts at our institution.

Methods All patients who underwent skin-sparing or nipple-sparing mastectomy followed by immediate DTI or TSR from 2011 to 2021 at a large academic medical center were included. Intraoperative data included ADM use, mastectomy weight, and plane of implant placement. Post-operative data included the presence of mastectomy skin necrosis (MSN), nipple areolar complex (NAC) necrosis, seroma, hematoma, infection, or capsular contracture. Demographic data included age, race, ethnicity, BMI, and comorbidities. Data analysis included descriptive statistics, Mann-Whitney for continuous variables, and Fisher's Exact tests for categorical variables.

Results Two-hundred ninety-seven patients were included in the study. Of these, 272 (91.6%) underwent TSR, and 25 (8.4%) DTI. A higher percentage of patients who received chemotherapy underwent TSR (55% vs 32%, p = 0.025). Patients who underwent DTI had a higher rate of NAC necrosis (16% vs 1.5%, p=0.002) and dehiscence (28% vs 11.9% p=0.032). There was no difference in the rate of infection, seroma, hematoma, or MSN between types of reconstruction. Regardless of procedure, higher BMI (p<0.001), history of diabetes (p=0.03), higher preoperative grade ptosis (p=0.010), and larger mastectomy resection weights (p=0.002) were associated with a higher risk of any complication. For either DTI or TSR, higher grade ptosis was specifically associated with an increased risk of developing MSN (p=0.025) and NAC necrosis (p=0.045). Pre-pectoral placement was not significantly associated with risk of NAC or MSN. Prior tobacco use was associated with a higher risk of infection (p=0.037) and dehiscence (p=0.029).

Conclusions This single-institution study suggests that TSR may still be preferred in alloplastic reconstruction to minimize the risk of NAC necrosis and wound dehiscence. Pre-pectoral placement did not significantly affect the risk of MSN or NAC necrosis and should be considered for all patients as it leads to less donor site morbidity and pain as well as prevents animation deformity.2 Lastly, these results highlight known higher risk conditions for alloplastic reconstruction including higher degrees of ptosis, history of diabetes or tobacco use, and higher BMIs.

References 1. Srinivasa DR, Garvey PB, Qi J, et al. Direct-to-Implant versus Two-Stage Tissue Expander/Implant Reconstruction: 2-Year Risks and Patient-Reported Outcomes from a Prospective, Multicenter Study [published correction appears in Plast Reconstr Surg. 2018 Feb;141(2):532]. Plast Reconstr Surg. 2017;140(5):869-877. doi:10.1097/PRS.0000000000003748 2. Fracol M, Feld LN, Chiu WK, Kim JYS. An overview of animation deformity in prosthetic breast reconstruction. Gland Surg. 2019;8(1):95-101. doi:10.21037/gs.2018.09.09

Purpose Many patients who require breast reconstruction prefer a flap-based approach for various reasons, including the permanence and the aesthetic benefit of a natural-looking and feeling breast. For patients who desire autologous breast reconstruction following mastectomy but lack adequate donor site volume, the authors utilize a novel Hybrid Flap, Prepectoral Acellular Dermal Matrix (HyPAD®) approach. In this technique, the deep inferior epigastric perforator (DIEP) flap is augmented with stacked acellular dermal matrix (ADM). The purpose of this study is to quantify the soft tissue augmentation and core projection achieved with this technique during autologous flap-based breast reconstruction.

Methods Consecutive patients who underwent the HyPAD® technique during the study period (August 2021 to December 2022) were identified. All patients lacked adequate donor site volume and wished to avoid the placement of implants during their reconstruction. Demographic information and outcomes were assessed. Intraoperatively, the weight (grams, g) of the mastectomy specimen, flap donor site, and stacked ADM were recorded.

Results During the study period, twenty-one patients (n=21) were identified. The mean age of patients at the time of surgery was 48.9 years. The mean body mass index (BMI) was 24.1 kg/m2. The mean mastectomy specimen weight was 436.4 g and the mean flap weight was 373.8 g, posing an average discrepancy of 14.3%. On average, the weight of the ADM used to augment the flap was 83.4 g. This weight accounted for 18.2% of the total reconstructed breast weight on average.

Conclusion The use of ADM during autologous breast reconstruction provides patients with an alternative to implants that allows them to obtain their desired breast volume. Given the aesthetic impact that ADM has on the total amount of flap weight and projection, it is recommended that the HyPAD® technique be considered for patients who desire a breast that cannot be restored with their own flap weight and yet wish to avoid implants.

Introduction: The onset of the COVID-19 pandemic resulted in significant changes to the surgical caseload for various surgery departments around the United States. As medical institutions prioritized resources for the expected increase in patient volumes due to SARS-CoV-2 viral infection, surgical departments saw a decrease in non-emergent and elective surgical procedures. Reduction mammaplasties, which are largely covered by insurance, are among the elective procedures that provide significant revenue to the hospital. This expected decline in procedures suggests a potential decline in revenue provided by the plastic surgery department of a hospital. The purpose of this study is to analyze the loss of revenue experienced by a single medical institution due to changes in breast reduction mammoplasty volumes during the COVID-19 pandemic.

Methods: Upon Institutional Review Board approval, using the Augusta University Medical Center's Financial Billing Data, 373 patients that underwent bilateral reduction mammoplasty were queried. A time horizon of March 2019 to March 2022 were used to determine the pre- and post-COVID caseload and charges that were incurred. Statistical analysis to compare the 12 months pre- and 24 months post-COVID was conducted using two-samples of equal variance t-test and F-test confirming equal variance.

Results: There was a statistically significant increase in the number of reduction mammoplasties performed per month from the year prior to the onset of COVID-19 (March 2020) to the 2 years after (6.6 to 11.4 per month, p-value 0.012). There was a statistically significant increase in the per-month charges from the AU Health system for reduction mammoplasties for the same time period ($31,780.92 to $52,113.34 per month, p-value 0.021). Although there was an increase in per-month revenue from reduction mammoplasties, this increase failed to reach statistical significance ($7,059.95 to $10,423.51 per month, p-value 0.058)

Conclusion: The plastic surgery department saw a statistically significant increase in reduction mammaplasty cases and subsequent charges in the post-COVID cohort. These findings suggest that the emergence of a nationwide pandemic did not necessarily lead to a decrease in the volume of non-emergent surgical cases despite an expected decrease in caseload due to the need to reallocate hospital resources. On the contrary, there was an increase in caseload suggesting that there may be other factors contributing to patients pursuing reduction mammoplasty post-COVID including convenience resulting from time off due to the pandemic, meeting insurance-covered reduction criteria, and projected recovery time.

Title: Current State of Evidence-Based Long-Term Monitoring Protocols for Cancer Recurrence in Post-Mastectomy Breast Reconstruction Patients

Background: Breast cancer is the most common malignancy affecting women worldwide, accounting for nearly 25% of cancers in women. While screening and advances in management have increased lifespan in breast cancer patients, locoregional recurrence has been estimated to have a 3-8% 5-year incidence.1 Current guidelines for breast reconstruction monitoring are controversial, with conflicting evidence supporting imaging or physical examination alone. We sought to evaluate the current state of evidence-based long-term monitoring protocols for patients who have undergone mastectomy and breast reconstruction.

Methods: Guidelines issued by the American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), American Society of Plastic Surgeons (ASPS), and American College of Radiology (ACR) were evaluated for recommendations on clinical examination and imaging. The references were reviewed for level of evidence and conclusions.

Results: Evidence-based clinical practice guidelines from professional organizations conflict in their recommendations for monitoring of cancer recurrence after mastectomy and breast reconstruction. Most organizations (ASCO, NCCN, ASPS) agree on the utility of annual clinical exams, with more frequent exams in the first six years.2 Evidence suggests that physical examination is sufficient to detect local cancer recurrence, with imaging only if there is concern for recurrence in patients who have undergone post-mastectomy implant-based reconstruction.3 No surveillance imaging is recommended by ASCO, NCCN, or ASPS; however, ACR recommends mammography or digital breast tomosynthesis for autologous reconstruction, and found no evidence to support screening with implant-based reconstruction.4 While some studies found utility in screening mammography for autologous reconstruction, others found that there was no difference in 5-year survival rate for patients who underwent surveillance imaging, symptomatic imaging, or no imaging.5 However, recommendations are based on minimal level I evidence from systematic reviews and primarily level III evidence.

Conclusion: Breast cancer patients need continued monitoring following breast reconstruction. While professional organizations all agree that clinical examinations are a vital component of recurrence detection, recommendations conflict regarding surveillance imaging. Further research is necessary to assess the utility of post-mastectomy imaging for cancer recurrence surveillance.

References:

1. Abe, O., Abe R., Enomoto K., et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. The Lancet. 2005;366(9503):2087-2106. doi:10.1016/S0140-6736(05)67887-7

   2. Khatcheressian JL, Wolff AC, Smith TJ, et al. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-Up and Management Guidelines in the Adjuvant Setting. JCO. 2006;24(31):5091-5097. doi:10.1200/JCO.2006.08.8575

   3. Barnsley GP, Grunfeld E, Coyle D, Paszat L. Surveillance Mammography following the Treatment of Primary Breast Cancer with Breast Reconstruction: A Systematic Review: Plastic and Reconstructive Surgery. 2007;120(5):1125-1132. doi:10.1097/01.prs.0000279143.66781.9a

   4. Heller SL, Lourenco AP, Niell BL, et al. ACR Appropriateness Criteria® Imaging After Mastectomy and Breast Reconstruction. Journal of the American College of Radiology. 2020;17(11):S403-S414. doi:10.1016/j.jacr.2020.09.009

   5. Shammas RL, Broadwater G, Cason RW, et al. Assessing the Utility of Post-Mastectomy Imaging after Breast Reconstruction. Journal of the American College of Surgeons. 2020;230(4):605-614e1. doi:10.1016/j.jamcollsurg.2020.01.006

Purpose Three-dimensional (3D) printing has been successfully used in several plastic and reconstructive surgery sub-specialties. For example, in craniomaxillofacial surgery, 3D printed constructs have facilitated faster operative times and significant improvements in clinical and patient outcomes. However, its use in the field of autologous breast reconstruction is still emerging. This scoping review aimed to characterize 3D printed constructs and their clinical impact in autologous breast reconstruction.

Methods We searched PubMed, Embase, Web of Science, Cochrane, and Scopus and retrieved 252 articles, 11 of which met our inclusion criteria. From these articles, we extracted data regarding the 3D printed construct, including the method, material, and cost, as well as how the construct was used in surgery. In addition, we collected data on the outcomes reported in the literature, including accuracy of the construct, the surgical planning time, intraoperative time, length of hospitalization, number of postoperative complications and flap failures, cosmesis, and patient satisfaction.

Results We identified 11 articles describing 137 3D printed constructs. The utilization of 3D constructs in breast reconstruction was classified into three types: Type IA breast models (2.9%, n=4), Type IB breast molds (32.8%, n=45), and Type II perforator templates (64.2%, n=88). Breast models were positive-space constructs of the breast that help determine the desired flap projection compared to a contralateral breast. Breast molds were negative-space constructs of the breast that aided the surgeon in creating shape and volume of the autologous flap intra-operatively. Finally, perforator templates were printed from pre-operative imaging scans and used to localize perforator vessels. Most constructs were used both pre- and intra-operatively (64.2%, n=88). The most common procedure that used 3D printed constructs were deep inferior epigastric perforator (DIEP) flap procedures (67.9%, n=93). Three studies on perforator templates (Type II) reported significant reductions in intraoperative time and reductions, but not significantly so in postoperative complications, reoperations, or flap failures. Other outcomes measured included breast mold (Type IB) volume and width accuracy, perforator template (Type II) identification accuracy, cosmesis, flap projection, patient satisfaction, and surgeon perception of the construct.

Discussion We performed a scoping review of the use of 3D printing in autologous breast reconstruction. We created a new classification system to describe the 3D printed constructs and to better characterize their functionality and clinical impact. Breast models (Type IA) and breast molds (Type IB) were primarily used to achieve symmetry and to improve cosmesis. Outcomes focused on objective appearance (e.g., flap projection, breast width, breast volume) and subjective assessment (e.g., cosmetic outcomes) of the breasts post-surgery. Perforator templates (Type II) were primarily used for flap design and inset to reduce operative time. Outcomes centered on postoperative complications and operating time, which encompassed perforator identification time and flap harvest time. Our results suggest that 3D printing represents a promising new technology in autologous breast reconstruction. Future studies comparing 3D printed construct use to control cases are needed to clarify the clinical impact, and our classification system can provide a framework on how to guide future comparison studies based on the construct and its outcomes.

Introduction The use of irrigation with bacitracin-containing solution has been common among surgeons, as it was widely thought to have anti-bacterial properties and to prevent post-operative infection. Current literature, however, suggests that antibiotic-containing irrigation confers little added benefit; some studies suggest a partial benefit, others suggest no benefit or perhaps even detriment to the patient [1, 2]. On January 31, 2020, the Federal Department of Agriculture (FDA) instituted a ban on bacitracin-containing irrigation for operative use. Despite the institution of a nationwide ban on perioperative bacitracin-irrigation, some surgeons continued to use it, possibly due to a perception among surgeons that antibiotic-containing solutions were unlikely to cause harm and that the literature did not form a consensus on outcomes for patients who did not receive antibiotic-containing irrigation versus those who did. This study aimed to determine whether bacitracin has a beneficial effect on postoperative infection rates by analyzing infection rates before and after the FDA ban on bacitracin irrigation.

Methods A single-institution retrospective chart review was conducted. Eligible patients underwent implant-based breast reconstruction following total mastectomy between October 1, 2016 and July 31, 2022. Procedure date, reconstruction type, patient comorbidities, use of bacitracin irrigation, post-operative infection, and secondary outcomes were collected. Univariate and multivariable logistic regression analysis was performed.

Results A total of 188 female patients aged 30-83 were included in the study, who underwent implant-based reconstruction procedures on 345 breasts. Twenty-seven (14%) pre-ban procedures resulted in post-operative infection and 21 (14%) post-ban procedures resulted in post-operative infection. Nine (13%) procedures involving bacitracin irrigation use resulted in a post-operative infection; of these procedures, 4 took place prior to the bacitracin ban and 5 took place after the bacitracin ban. Bacitracin use did not protect against infection in univariate or multivariable analysis. Age under 50 years was associated with increased risk of postoperative infection (p=0.03). The presence of comorbidities, smoking status, neoadjuvant chemotherapy, implant position prepectoral versus subpectoral, and laterality were not statistically significantly associated with postoperative infection development.

Conclusion The use of bacitracin-containing irrigation solution does not decrease the risk of postoperative infection. As bacitracin is no longer FDA approved for use in irrigation, further research is required to explore the optimal antibiotics for inclusion in pocket irrigation for implant-based reconstruction.

References 1. de Jonge, S.W., et al., Systematic Review and Meta-Analysis of Randomized Controlled Trials Evaluating Prophylactic Intra-Operative Wound Irrigation for the Prevention of Surgical Site Infections. Surg Infect (Larchmt), 2017. 18(4): p. 508-519. 2. Tirrell, A.R., et al., Bacitracin for Injection Recall: Impact on Immediate Breast Implant Surgical Outcomes. Breast J, 2022. 2022: p. 1389539.