Scientific Abstract Presentations: Breast Session 7 Friday, September 27 Fri, Sep 27 5:00-6:00 p.m. PDT

Purpose: During surgery, neuromuscular blocking agents (NMBA) are used to facilitate endotracheal intubation and to prevent muscle fibre contractions that may interfere with surgical dissection. Literature regarding the use of NMBAs intraoperatively and the risk of developing postoperative pulmonary complications (PPCs) remains controversial. This study investigates whether intraoperative NMBA increases the risk for PPCs in DIEP-free flap breast reconstruction patients.

Method: The University Health Network Quality Improvement Review Committee approved this retrospective observational chart review (ID#QIRC23-0609). All adult females at high risk or diagnosed with breast cancer who underwent a DIEP post-mastectomy between January 2018 and December 2022 at Toronto General Hospital were eligible for inclusion. Extracted data were statistically analyzed in Python, version 3.6.9; p-value <0.05 was considered statistically significant. Kruskal-Wallis and Fisher's exact tests were used for continuous variables, Chi-squared tests for binary variables.

Results: 503 patients with a median age of 51 [45.0,57.0] years were included. Most patients underwent immediate breast reconstruction n=318 (63.5%) and had bilateral DIEPs n=297 (59.3%). Ten patients developed PPCs. There was no significant difference in rocuronium dose (no PPCs;170mg [140.0, 218.8], PPCs; 182.5mg [155.0, 197.5, p=0.905), time from the last rocuronium dose to the end of surgery (no PPCs; 169.5min [122.8, 226.0], PPCs; 153min [120.2, 181.5], p=0.51) or number of rocuronium doses received (No PPCs; 6.0 doses [4.0,8.0], PPCs; 7.0 doses [5.0,8.0], p=0.456) between groups. No difference was found in cardiac events (p=0.997), pulmonary embolism (p=1), reoperation (p=1), flap loss (p=1) or other postoperative complications (p=0.585).

Conclusions: Intraoperative use of NMBAs does not increase the risk of developing PPCs and these patients do not have an increased risk of developing further postoperative complications.

Teaching Objectives: Discuss the relationship between NMBAs and the risk of postoperative pulmonary complications.

Introduction

Anterior-posterior flipping of a breast implant can result in suboptimal aesthetics and emotional distress after prepectoral breast reconstruction. With use of smooth round implants, providers require education regarding the risk factors associated with implant flipping and strategies to correct implant flipping in the clinical setting. Risk factors for implant flipping include use of smooth, round, highly cohesive, and large implants with high projection. Implant flipping is often detected by the patient after a change in shape of the breast that may be associated with discomfort. Due to the flattened posterior aspect of the implant sitting against the mastectomy flap, patients experience flattening of the face of the breast with contour irregularities of the superior and inferior poles. The purpose of this study is to present a novel four-step technique to correct implant flipping with minimal discomfort that can be easily implemented by providers in the clinical setting.

Methods

1) The patient is placed in an exam chair or standing while bending forward at the waist to about 45 degrees

2) The provider then applies equal and direct pressure on the lateral and medial sides of the implant to decrease the flatness of the posterior aspect of the implant that abuts the mastectomy flap.

3) With pressure applied, the provider then presses the medial aspect of the implant towards the chest wall while pulling the lateral aspect of the implant towards the center of the breast mound.

4) In the transition from step 2 to step 3, the providers hands should move from the lateral and medial poles of the breast to the superior and inferior poles of the breast. Examine the breast to ensure the implant is in the correct orientation. Multiple attempts may be needed to correct the flipping of the implant.

Results

Successful implant flipping is demonstrated in pre-procedural and post-procedure photographs in three patients. The method of implant flipping is demonstrated in a video.

Conclusions

Breast implant flipping is distressing for patients after prepectoral breast reconstruction and can result in suboptimal aesthetics. Surgical pocket control with possible implant exchange remains the gold standard to correct a flipped implant; however, not all patients desire or warrant surgical intervention for correction of the breast pocket. The implant can be safely manipulated in clinic with minimal pain to restore its original placement using a simple four-step manipulation.

Introduction: Loss of sensation after mastectomy can be devastating for patients' quality of life, and even a risk for injury. Prior studies have shown successful reinnervation in autologous breast reconstruction, but this has not been widely studied in implant-based reconstruction, which is more challenging due to the frequent absence of a distal nerve stump target for reinnervation.

Methods: Our group began performing nerve reconstruction in conjunction with breast reconstruction following mastectomy in April 2021. From April 2021-May 2022, all patients who underwent nerve reconstruction with implant-based breast reconstruction were followed postoperatively with the Semes Weinstein monofilament testing as well as the BREAST-Q Sensation Module.

Results: Sixty-five patients were included in the analysis, representing 113 breasts. Fifty-eight of these patients (106 breasts) were nipple-sparing mastectomies. Most patients (n=34) underwent Direct-to-Implant (DTI) reconstruction, while 24 underwent staged alloplastic reconstruction with a tissue expander and 8 underwent autologous reconstruction. Breast resection volume ranged from 122 to 1358g, with mean intercostal nerve dissection 5.2cm (range 0-16cm). On average, a 440cc implant was used for DTI reconstruction (range 210-755cc); if a tissue expander was placed, on-table fill averaged 400cc (range 250-600cc). Using the BREAST-Q sensation module and Semes Weinstein monofilament testing, we observed improved sensation over time, with no abnormal sensation or pain.

Conclusions: While more validated tools are necessary to assess the overall quantitative return of breast sensation after nerve reconstruction, our data suggests positive impact of breast sensation on patient quality of life which increases with time from mastectomy.

Introduction

Advances in the early detection and treatment of breast cancer have altered the landscape of disease prognosis dramatically, with a five-year relative survival rate of 91% (1). Many women are living long lives with breast cancer or in remission, bringing forth the importance of survivorship care and treatment longevity. Anesthesia and loss of protective sensation of reconstructed breasts is becoming increasingly recognized as a problem. Reports of accidental burns in insensate reconstructions emphasize the importance of understanding and optimizing the recovery of breast sensation, especially temperature sensitivity (2). Previous studies from our group found superior tactile sensitivity in autologous breast reconstruction compared to device-based reconstruction (3). In this study, we build on our prior work by investigating the regional pattern of temperature sensitivity in alloplastic and autologous breast reconstruction.

Methods Women undergoing mastectomy with immediate two-stage alloplastic reconstruction or neurotized deep inferior epigastric perforator (DIEP) flap reconstruction were prospectively followed. Temperature testing was performed by blinded patient identification of a heat pack or a cold pack on five different regions of the breast. All reconstructed breasts were grouped based on surface area, and statistical analysis was performed in R to compare hot and cold sensitivity between the two types of reconstruction.

Results 100 patients (181 breasts) were included: 79 breasts with alloplastic and 102 breasts with autologous reconstruction. There were no differences in preoperative temperature sensitivity between the two groups, nor between regions of the breast (p>0.05). The average follow-up time for the alloplastic group was 16.34 months, and the average follow-up time for the autologous group was 14.24 months. Postoperatively, heat and cold sensitivity were the least affected in the superior and medial regions of the breast and the most affected at the nipple-areolar complex (NAC). Cold sensitivity was comparable between the two reconstruction types across all surface areas (p>0.05), with the only difference in heat sensitivity in the superior regions of breasts with a surface area greater than 250 cm2 (100% in alloplastic vs. 47.6% in autologous, p=0.01). In a sub-analysis of immediate and delayed DIEP flaps, immediate flaps had improved heat sensitivity at the NAC (38.3% vs. 10.0%, p=0.037).

Conclusion Both hot and cold sensation of the reconstructed breast are most affected at the NAC. Whilst neurotized autologous flaps have superior recovery of pressure sensation compared to alloplastic reconstruction, the same pattern was not seen with recovery of temperature sensation. These findings suggest distinct mechanisms of recovery of these two sensory modalities; further study is ongoing to elucidate the timeline of temperature sensitivity recovery.

References 1) American Cancer Society. Cancer Treatment & Survivorship Facts & Figures 2022-2024. Atlanta: American Cancer Society;2022.

2) Habibi K, Delay E, Sarfati I, Duteille F, Clough KB, Atlan M. Lessons Learned From Twenty-Eight Cases of Burns Following Breast Reconstruction: An Underestimated Complication Requiring Inclusion in Consent Information. Aesthet Surg J. 2021;41(7):NP773-NP779. doi:10.1093/asj/sjab027

3) Huang H, Wang ML, Ellison A, Otterburn DM. Comparing Autologous to Device-Based Breast Reconstruction: A Pilot Study of Return in Breast Sensation. Ann Plast Surg. 2022;88(3 Suppl 3):S184-S189.doi:10.1097/SAP.0000000000003073

Introduction Implant based reconstruction is not always feasible when mastectomy flap viability is poor. Rather than returning to the operating room for staged breast reconstruction with tissue expansion (TE), patients may instead opt for delayed direct to implant (dDTI) reconstruction. This study aimed to assess the feasibility of dDTI after patients "go flat" after their mastectomy.

Methods Patients unable to undergo breast reconstruction at the time of their mastectomy and who later underwent implant placement without tissue expanders between 2022 and 2024 were included in this study. These patients were compared to patients who underwent tissue expander to implant based reconstruction. A loose BMI and radiation-matched subsample was created for subanalysis.

Results A total of 66 patients or 103 breasts were included in the study (77 TE and 26 dDTI breasts). The average age was 48 ± 11 years, and average BMI was 27.2 ± 5.3 kg/m2. The mean time between mastectomy and dDTI was 132.8 ± 182.2 days. dDTI had less complications than TE (4.8% vs 32.1%, p = 0.01). Patients with TE had significantly higher odds of having complications compared to dDTI (odds ratio, 9.4 [1.2 – 74.3], p = 0.03).

Conclusions dDTIs appear to be a safe alternative to tissue expansion, especially when implant based reconstruction is not feasible due to poor blood supply on SPY angiography. This technique saves the patient, at minimum, an additional surgery and multiple clinic visits that would have been required if tissue expanders were used.

Purpose: Periprosthetic infection (PPI) is a rare complication associated with alloplastic breast reconstruction resulting in reconstructive failure, delay of adjuvant therapies, and re-operations. Despite multiple observational cohort studies, the optimal PPI management remains unclear. The aim of this study was to develop a clinical prediction tool to guide management of PPI.

Methods: A multicenter retrospective cohort study was conducted. Consecutive breast cancer patients who underwent immediate alloplastic breast reconstruction between 2010-2020 were included. Data was collected including patient, oncologic, and reconstructive factors for patients whose postoperative course was complicated by either cellulitic or periprosthetic infection. Two models were created for prediction of progression from cellulitis to PPI and from breast infection to reconstructive failure.

Results: A total of 1468 patients (2165 breasts) were included. The incidence of infection was 7.1% (n=145). The implant reconstruction was salvaged in 67.1% (n=104) of cases. The first model, predicting progression from cellulitis to periprosthetic infection, had good predictive accuracy with an AUC of 0.61 (95% CI 0.53-0.70; p<0.001). The second model, predicting progression to reconstructive failure had good predictive accuracy with an AUC of 0.79 (95% CI 0.71-0.87; p<0.001). Models were converted into risk stratification tools where five clinical variables were identified for a prediction scoring model with weighted points for each tool.

Conclusions: This study presents novel clinical prediction tools with good predictive accuracy. Application of these prediction tools can assist the clinician in making evidence-based treatment decisions for treatment of PPI following alloplastic breast reconstruction. Future research will aim to prospectively validate treatment algorithms and improve reconstructive success.

Learning Objectives: To identify prognostic factors in the progression of breast cellulitis to PPI and reconstructive success following PPI. To discuss how these prognostic factors can be applied to guide clinical management of breast infection following alloplastic breast reconstruction.

References: 1. Panchal H, Matros E. Current trends in post-mastectomy breast reconstruction. Plastic and reconstructive surgery. 2017;140(5):7S. 2. Franchelli S, Pesce M, Baldelli I, Marchese A, Santi P, De Maria A. Analysis of clinical management of infected breast implants and of factors associated to successful breast pocket salvage in infections occurring after breast reconstruction. International Journal of Infectious Diseases. 2018;71:67-72. 3. Reish RG, Damjanovic B, Austen Jr WG, Winograd J, Liao EC, Cetrulo CL, et al. Infection following implant-based reconstruction in 1952 consecutive breast reconstructions: salvage rates and predictors of success. Plastic and reconstructive surgery. 2013;131(6):1223-30. 4. Kato H, Nakagami G, Iwahira Y, Otani R, Nagase T, Iizaka S, et al. Risk factors and risk scoring tool for infection during tissue expansion in tissue expander and implant breast reconstruction. The Breast Journal. 2013;19(6):618-26. 5. Hassan AM, Biaggi-Ondina A, Asaad M, Morris N, Liu J, Selber JC, et al. Artificial intelligence modeling to predict periprosthetic infection and explantation following implant-based reconstruction. Plastic and reconstructive surgery. 2023;152(5):929-38.

Introduction: Mastectomy with breast reconstruction is an important component of comprehensive breast cancer care. Though commonly with tissue expanders, a more natural breast is often found with free flap reconstruction. Understanding the risk profile of patients for free flap surgery is critical. Common risk stratification tools, include the frailty index, sarcopenia, and the body mass index (BMI). The BMI is especially controversial. The waist-to-hip ratio, based on the theory that central adiposity (intra-abdominal adiposity) has been shown to be more predictive of complications than the BMI in the medical literature. We sought to prospectively determine if the waist-to-hip ratio is superior to the BMI in predicting complications in breast reconstruction.

Methods: Patients who were referred to the senior author for autologous breast reconstruction were included. Demographic data were collected. Body morphometric data were recorded. All flaps were deep inferior epigastric flaps anastomosed to the internal mammary vessels. A minimum six-month follow up was required, with complications recorded, including infection requiring an additional course of antibiotics or surgical intervention, symptomatic fat necrosis, poor wound healing requiring surgical intervention, loss of reconstruction, and death. The BMI was calculated by the standard methodology. The waist-to-hip ratio was calculated as waist circumference at the umbilicus (cm)/hip circumference at the widest point (cm). Multivariate regression was performed to determine which variables were independent predictors of complications. All preoperative measures of risk, including frailty index, BMI, waist-to-hip, waist-to-height, and body surface area, were included as covariates.

Results: A total of 41 patients were included in this study, with 12 (29%) having complications. A majority of these were symptomatic fat necrosis; one patient had wound difficulties requiring surgery. Demographic data, including the BMI, age, waist-to-height ratio, modified frailty index, and body surface area were statistically equivalent whether a complication was present or not. The waist-to-hip ratio was 0.88 for patients without complications and 0.96 with complications. On multivariate regression, the waist-to-hip ratio was the only significant morphometric factor (p = 0.047, OR 22.5) with a ratio of 0.85 correlated to a 50% risk. Above this threshold, 35% of patients had a complication, compared to 10% below. The BMI did not correlate with complications.

Conclusion: The waist-to-hip ratio is a body morphometric measurement that provides a superior prediction of complications in our series of tissue expander-based reconstruction patients, suggesting that it should replace the BMI in preoperative measurements and in patient counseling.

Purpose: Inpatient length of stay is a critical metric for healthcare efficiency. Understanding risk factors for prolonged LOS (pLOS) enables better preparation and planning for breast reconstruction, improving patient satisfaction and outcomes. This study aims to identify risk factors associated with pLOS in patients undergoing breast reconstruction.

Methods: This is a retrospective cohort study including patients undergoing free tissue postmastectomy breast reconstruction from 2005 to 2020 in the province of Ontario, Canada (population 14 million). Patients were identified from a prospectively maintained administrative database stored at the Institute for Clinical Evaluation Sciences. Patients were dichotomized according to whether they encountered an extended postoperative hospital LOS, defined as a stay greater than the 95th percentile for the cohort (≥8 days). Univariate and multivariate logistic regression analyses identified risk factors associated with pLOS.

Results: Among the 2,339 patients in the study, 121 experienced pLOS. Significant factors associated with a pLOS included year of reconstruction (aOR [adjusted odds ratio] 0.9, 95% confidence interval [CI] 0.81 to 0.90, p < 0.0001), reconstruction at non-teaching hospitals (aOR 2.7, 95% CI 1.6 to 4.4, p < 0.0001), lower neighbourhood income quintile (quintile 1 v. quintile 5: aOR 3.7, 95% CI 1.5 to 8.9, p=0.004), and higher levels of social deprivation (quintile 5 v. quintile 1: aOR 2.7, 95% CI 1.1 to 6.3, p=0.025). Conversely, age, Charlson comorbidity index, rurality, and local health integration network (LHIN) affiliation showed no significant correlation with prolonged LOS.

Conclusion: Our study indicates that pLOS after breast reconstruction in Ontario is predominantly influenced by socio-economic and institutional factors, notably treatment in non-teaching hospitals and lower socio-economic status. These findings highlight the importance of comprehensive care planning that addresses medical and socio-economic needs.

Introduction: Breast cancer is the second leading cause of cancer-related mortality among women in sub-Saharan Africa (SSA), where low survival rates are in part due to late presentation of women with advanced stage disease. As fear of mastectomy has been suggested to be the most significant factor linked to delays, it remains unknown if the availability of breast reconstruction has the potential to ameliorate that fear and encourage earlier presentation (1). Therefore, our study sought to explore the sociocultural attitudes and perceptions of breast reconstruction in SSA women with breast cancer.

Methods: We designed an interpretive description, a noncategorical qualitative method suited for applied healthcare research to address our question. Women were eligible for our study with a diagnosis of breast cancer (stage 0-III) and were recruited from breast cancer clinics at St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia and Komfo Anokye Teaching Hospital in Kumasi, Ghana. We conducted semi-structured in-person interviews in English, Amharic and Twi utilizing the assistance of native interpreters. Narratives were inductively analyzed in a team based iterative approach.

Results: 45 total women (20 from Ethiopia, 25 from Ghana) participated in our study. Approximately half of the women had undergone mastectomy at the time of the interview. Our findings highlighted complex, multifaceted cultural attitudes surrounding breast reconstruction in this population. We identified three major themes that shaped women's perceptions. First, women held a dichotomous view of their body in terms of function versus aesthetics. Some saw breasts as purely utilitarian but would later describe the emotional impact of mastectomy and their view that the restoration of "their self, their image… and their confidence" could be achieved with breast reconstruction. Second, women projected age and life stage as important factors in the appropriateness of breast reconstruction. Women tended to think that younger women, or those "looking for a husband" would be better suited to achieve the social benefits from reconstruction. Finally, the high cost and inaccessibility of medical care underscored a reluctance towards further utilization of healthcare resources. The idea of a complication leading to snowballing medical needs and fees was a prohibitive risk for many women. Importantly, our findings could be tempered by an underlying lack of education or awareness of breast reconstruction shaping women's initial reactions.

Conclusion: As initiatives to improve global surgical capacity become more widespread within the plastic surgery community, we caution providers to think carefully about the deep complexities underlying the current landscape of breast cancer treatment. Strategies to better serve this population will involve patient education initiatives combined with further understanding of culturally held beliefs about bodies, disease, and the existing inequalities in the healthcare system.

1. Martei YM, Vanderpuye V, Jones BA. Fear of Mastectomy Associated with Delayed Breast Cancer Presentation Among Ghanaian Women. The Oncologist. 2018;23(12):1446-1452. doi:10.1634/theoncologist.2017-0409

PURPOSE Lymphedema continues to affect an increasing number of patients, especially as rates of lymph node biopsy and dissection increase for oncologic treatment.(1) Lymphedema in the United States is rarely diagnosed until the patient develops symptoms and access to providers who specialize in lymphedema treatment remains limited for many patients. ImpediMed's SOZO device is a tool advertised to help identify patients at risk for developing lymphedema earlier on through bioimpedance (L-Dex) scores.(2) Formal lymphedema evaluation at most lymphedema centers involves more invasive testing such as indocyanine green (ICG)-lymphography, magnetic resonance lymphangiography, or lymphoscintigraphy. These tests allow for direct visualization of lymphatic function, but are more invasive, expensive, and inaccessible for many patients.(3) We sought to compare bioimpedance (L-Dex) scores to results seen after ICG lymphography to study whether L-Dex scores accurately correlate with lymphedema diagnosis and severity. METHODS A retrospective chart review was conducted utilizing patient encounter information from a single plastic surgeon. Patient encounters dated from 2022 to 2024 were considered. Of 1,800 individual patients, 38 had undergone SOZO testing with a resulting bioimpedance score. Of those 38, 10 patients underwent formal ICG-lymphography. Lymphography scores were categorized on a scale of 0 to 5; 0: linear pattern, 1: delayed linear pattern; 2: dermal backflow (DBF) in 1 site, 3: DBF in >2 sites, 4: stardust pattern, 5: diffuse pattern. Data analysis included creating a trendline to determine whether correlation existed between L-Dex scores and lymphedema severity seen on ICG-lymphography. RESULTS Of the ten patients, nine were females having undergone mastectomy for breast cancer and one male patient had undergone resection for melanoma. Of the nine patient's status post mastectomy, six had undergone axillary lymph node dissection. Of all 10 patients, eight had received radiotherapy. Age at time of SOZO ranged from 38 to 75 years. L-Dex scores varied between -9.7 to 27.0. ICG lymphography scores varied from 0 to 5. A scatterplot and line of best fit were generated, resulting in an R2 of 0.008. CONCLUSION Although the SOZO device is an accessible and cost-effective tool, we found that bioimpedance scores obtained from SOZO did not correlate with lymphedema severity seen on ICG-lymphography (R2=0.008). Development of additional screening tools that are affordable and widely accessible will useful in identifying patients at risk for developing lymphedema and allowing for earlier intervention. Such tools will also assist in determining which patients would benefit from undergoing more invasive and costly testing, like ICG-lymphography, which may help decrease overall healthcare costs and improve healthcare equity.

REFERENCES: 1. Sosa A, Lei X, Woodward WA, Chavez Mac Gregor M, Lucci A, Giordano SH, Nead KT. Trends in Sentinel Lymph Node Biopsies in Patients With Inflammatory Breast Cancer in the US. JAMA Netw Open. 2022 Feb 1;5(2):e2148021. doi: 10.1001/jamanetworkopen.2021.48021. PMID: 35147686; PMCID: PMC8837909. 2. "L-Dex® Score." ImpediMed, 7 June 2023, www.impedimed.com/resources/l-dex-score/. 3. Jørgensen MG, Toyserkani NM, Hansen FCG, Thomsen JB, Sørensen JA. Prospective Validation of Indocyanine Green Lymphangiography Staging of Breast Cancer-Related Lymphedema. Cancers (Basel). 2021 Mar 26;13(7):1540. doi: 10.3390/cancers13071540. PMID: 33810570; PMCID: PMC8063087.