Scientific Abstract Presentations: Breast Session 1 Thursday, October 9 Thu, Oct 9 1:30-3:00 p.m. CDT

Introduction: Periprosthetic infection rates in postmastectomy breast reconstruction remain a significant issue, and may result in explantation, with a large portion of patients choosing to forego reconstruction thereafter. This study aims to evaluate the use of both absorbable and non-absorbable prophylactic antibiotic cement to reduce infection rates in implant-based breast reconstruction.

Methods: A multi-institutional, retrospective review was performed of patients who underwent tissue expander (TE) reconstruction with both permanent and absorbable versions of antibiotic-loaded cement. Patients received either 1) polymethylmethacrylate (PMMA) plates loaded with vancomycin and tobramycin or 2) absorbable calcium sulfate (CS) beads or discs loaded with gentamycin and vancomycin. Demographics, medical history, perioperative details, and complications were collected. Comparisons were made between those who received non-absorbable PMMA and those who received absorbable CS.

Results: Two hundred eighteen TE reconstructions were performed on 139 patients. Ninety-two (42.2%) breasts received non-absorbable, antibiotic-loaded PMMA, and 126 (57.8%) breasts received absorbable, antibiotic-loaded CS. Six (2.8%) breasts had infections, with 1 (0.5%) occurring beyond 6 weeks post-operatively and 5 (2.3%) occurring within 6 weeks. Four of the 6 infected breasts had previous debridement due to wound dehiscence or mastectomy flap necrosis, and 1 occurred within the setting of an infected drain site. No TEs were lost due to infection. Antibiotic-loaded, non-absorbable PMMA and absorbable CS had no significant differences in infection rates (4.3% vs 1.6%, respectively).

Conclusion: Antibiotic-loaded cement can be effectively used for infection prevention with implant-based reconstruction. Non-absorbable PMMA and absorbable CS for local antibiotic delivery resulted in similar safety profiles.

Background: In implant-based reconstruction (IBR), surgeons must determine both implant position (pre-pectoral or sub-pectoral) and reconstruction timing (direct-to-implant [DTI] or two-staged). Pre-pectoral DTI reconstruction has gained increasing popularity due to its compelling advantages: pre-pectoral placement demonstrates reduced postoperative pain and higher patient satisfaction, while the single-stage DTI approach lessens surgical burden. However, DTI reconstruction has also been associated with increased revision rates.(1) Amidst this complex clinical landscape, the impact of implant cohesivity on primary, and especially re-operative surgical outcomes remains underexplored. This study evaluates the impact of implant cohesivity on complications, surgical revision rates, and aesthetic outcomes in both primary and revision DTI breast reconstruction to establish evidence-based guidelines for implant selection.

Methods: A retrospective cohort analysis was conducted on adult female patients who underwent unilateral or bilateral, skin- or nipple-sparing mastectomy, with pre-pectoral DTI breast reconstruction between January 2020 to August 2024. Reconstructions performed without tissue reinforcement matrices were excluded. Demographics, implant characteristics, complications, and reoperation patterns were recorded. Multivariable regression assessed associations between implant cohesivity and outcomes, controlling for confounders. Wilcoxon test examined the shift in implant cohesivity at revision.

Results: The cohort consisted of 249 patients undergoing 371 DTI breast reconstructions. Mean age was 50.5±10.1 years, and the mean BMI was 27.2±5.5. The median follow-up time was 361 (range: 122-1049) days. In the breast-level analysis, 106 (28.6%) were performed with low-cohesivity (LC) implants, 100 (27.0%) with medium (MC), and 165 (44.5%) with high cohesivity (HC).

Complications included rippling in 125 breasts (34%). HC implants demonstrated significantly lower rippling (OR=0.27, p<0.001) and contracture (OR=0.33, p=0.023) compared to LC implants. However, HC implants were associated with increased implant flipping (OR=8.87, p=0.049). Post-mastectomy radiation was associated with reduced rippling (OR=0.38, p=0.01) but increased contracture (OR=3.41, p=0.015).

Revision surgery was performed in 143 breasts (38.5%), among which 61 (42.7%) received revision for medical reasons, including positive margins, infection, hematoma, and painful contracture, and 82 (57.3%) received revision for cosmetic concerns. MC implants were associated with increased odds of reoperation (OR=1.38, p=0.018), while HC implants did not significantly increase reoperation risk. When stratifying by indications for revision, hypertension (OR=2.5, p=0.03) and smoking (OR=1.89, p=0.04) increased the likelihood of medical revisions. Among cosmetic revisions, fat grafting for rippling correction (21 breasts, 14.1%) achieved an 86% resolution rate. Wilcoxon analysis demonstrated a significant trend toward higher-cohesivity implant selection during revision surgery (p=0.048).

Conclusion: This analysis demonstrates distinct complication profiles associated with implant cohesivity in pre-pectoral DTI breast reconstruction. High-cohesivity implants showed superior performance in preventing rippling and contracture, though with an increased risk of implant flipping. The observed trend toward higher-cohesivity implant selection during revision surgery, coupled with successful fat grafting outcomes for rippling correction, suggests potential strategies for managing specific complications. As DTI breast reconstruction continues to evolve, understanding the relationship between implant cohesivity and outcomes provides valuable guidance for optimizing both primary and revision surgical approaches.

1. Basta MN, Gerety PA, Serletti JM, Kovach SJ, Fischer JP. A Systematic Review and Head-to-Head Meta-Analysis of Outcomes following Direct-to-Implant versus Conventional Two-Stage Implant Reconstruction. Plast Reconstr Surg. 2015;136(6):1135. doi:10.1097/PRS.0000000000001749

Background: Breast reconstruction following mastectomy is a significant consideration for many patients. Understanding the factors influencing these decisions can enhance patient counseling and optimize outcomes, particularly for those with breast cancer-related genetic mutations. Our study aims to explore the decision-making patterns regarding the type and timing of breast reconstruction among women with such mutations, with or without a breast cancer diagnosis.

Methods: We identified adult women with breast cancer-related genetic mutations who underwent mastectomy (risk-reducing or therapeutic for a known cancer diagnosis) at a single academic institution. High penetrance (BRCA1, BRCA2, CDH1, PALB2, PTEN, STK11, TP53) and moderate penetrance mutations (ATM, BARD1, CHEK2, NF1, RAD51C, RAD51D) were included. Patients were stratified based on receipt of breast reconstruction and timing (immediate vs delayed). Demographic, clinical, and treatment-related factors were compared by receipt of reconstruction and reconstruction timing.

Results: Among 357 patients, 59.4% (N=212) underwent breast reconstruction. Reconstruction rates were higher for risk-reducing mastectomy (74.2%) compared to therapeutic mastectomy (54.5%, p=0.001). Patients who underwent reconstruction were younger at genetic testing (median age 42.1 vs. 46.3 years, p<0.001) and mastectomy (43.7 vs. 47.8 years, p<0.001), with a lower BMI (25.0 vs. 27.5, p=0.002). Immediate reconstruction was more common (87.3%) than delayed (12.7%), especially following prophylactic mastectomy (100% vs. 81.5% for therapeutic, p<0.001). Patients who underwent nipple-sparing or skin-sparing mastectomies were more likely to have reconstruction compared to those with total mastectomy (p<0.001). Among those who had reconstruction, implants were preferred over autologous methods (63.7% vs. 36.3%). Most implant reconstructions involved a tissue expander (78.5%), while autologous reconstructions commonly utilized free abdominal (DIEP) flaps (55.8%, p=0.02). The sequence of genetic testing and breast cancer diagnosis significantly influenced both the receipt (p=0.001) and timing of reconstruction (p<0.001). High penetrance mutation carriers more frequently had immediate reconstruction compared to delayed (86.4% vs. 71.4%, p=0.03), although mutation type was not associated with the overall likelihood of undergoing reconstruction (p=0.90). Neither race nor parity significantly impacted reconstruction decisions.

Conclusion: Our study provides valuable insights into factors influencing breast reconstruction patterns among women with breast cancer-related genetic mutations. Younger age, lower BMI, and the type of mastectomy were associated with higher reconstruction rates. The sequence of genetic testing and cancer diagnosis also influenced decisions regarding reconstruction. These findings underscore the importance of multidisciplinary care to support personalized patient counseling and optimize outcomes.

Introduction: Resident involvement in complex microsurgical procedures is essential for advancing surgical training, yet it often raises concerns amongst patients and surgeons. While general surgical outcomes have been studied, the impact of resident participation in microsurgery remains underexplored. This study leverages a unique case control-like opportunity from a healthcare merger to evaluate plastic surgery resident involvement in a high-volume microsurgical breast practice.

Purpose: To evaluate the impact of plastic surgery resident involvement on postoperative outcomes in DIEP flap breast reconstruction, addressing the gap in research on resident participation in complex microsurgery.

Methods: A retrospective review was conducted on 395 patients who underwent DIEP flap reconstruction from December 2021 to May 2024. Patients were stratified into three cohorts: dual attendings without a resident (n = 174), with a plastic surgery resident (n = 147), or with a general surgery resident (n = 38). Demographics, operative details, and postoperative outcomes were analyzed, focusing on complication rates, flap ischemia time, infection, length of stay, and revisions. Statistical analysis was performed in R Studio using T-tests and Mann-Whitney U tests for continuous variables, Fisher's Exact tests for categorical variables, and Shapiro-Wilk tests for normality.

Results: Demographics, comorbidities, and treatment histories were similar across all cohorts. Flap ischemia time was marginally longer in the plastic surgery resident cohort (46 minutes vs. 39 minutes, p = 0.001), but the difference was not clinically significant. Resident involvement did not negatively impact any complication rate, including flap loss, reoperation, hematoma, seroma, wound dehiscence, skin necrosis, fat necrosis, and infection. Estimated blood loss and length of stay were comparable across all groups. Revision rates were also comparable between cases performed with and without resident participation (53.5%, 51.7%, p = 0.841).

Conclusion: Plastic surgery resident involvement in complex microsurgical cases is safe and does not compromise patient outcomes. Flap ischemia time was statistically, though not clinically, increased, with no statistically significant increase in total operative time. This research holds broad implications in surgical education, supporting the notion that resident involvement in complex microsurgical procedures is both safe and vital for developing the next generation of skilled plastic surgeons. Further discussion and studies are warranted to investigate efficiency, economic implications, and long-term patient outcomes.

PURPOSE: Engineering a patient-specific, in vitro breast cancer model holds the potential to revolutionize our understanding of disease progression and significantly improve treatment paradigms. Our laboratory has successfully developed a patient tissue-derived, engineered 3D platform that contains all cellular components found within the breast. Herein, we aim to 1) quantify breast cancer cell proliferation and migration in 'plain' collagen culture in response to varying concentrations of doxorubicin, and 2) compare this response when cancer cells are cultured within our biomimetic (BM) platform, fabricated from collagen and patient breast derived cells.

METHODS: Breast tissue from healthy female patients undergoing non-oncologic reduction mammaplasties was processed to isolate mature adipocytes, stromal vascular fraction (with immune cell components), and ductal epithelial organoids. Tri-layer 3D constructs, approximately 50µl volume each, were engineered in a 96-well plate: 1) a base layer of RFP-tagged triple negative breast cancer cells (TNBC), 2) a middle layer with either breast-derived components suspended in 0.3% collagen ("BM") or 0.3% collagen alone without cells ("Collagen"), and 3) a top layer of GFP-tagged human umbilical vascular endothelial cells (HUVEC). BM and Collagen constructs were treated in triplicate with the following doxorubicin concentrations: 0µM (no treatment), 1µM, 10µM, and 100µM. Constructs were incubated at 37°C under normoxic conditions (20% O2). Confocal imaging was performed immediately before (pre-treatment) and 2 days after (post-treatment) the addition of doxorubicin. An Imaris™ machine learning algorithm was built to measure vertical z-axis TNBC position, and a regression plane of cell location was reconstructed in RStudio. Forty-eight hours after doxorubicin treatment, tumor cells that exceeded one standard deviation from this plane were considered "migrated" towards the endothelial layer. Post-treatment tumor cell counts and mean z-axis distance of "migrated" cells were normalized to pre-treatment values.

RESULTS: Both pre- and post-doxorubicin treatment, confocal microscopy revealed ~800μm thick constructs with distinct TNBC, intermediary BM or Collagen, and HUVEC layers. Normalized post-treatment TNBC cell count was greater in BM wells than Collagen wells in all conditions, though not reaching statistical significance (p>0.05). The half maximal inhibitory concentration (IC50) was 3.43µM in Collagen and 5.11µM in BM constructs suggesting potential sequestration and/or metabolism of the chemotherapy by patient-derived cells. A greater percentage of TNBC were migratory in BM wells versus Collagen wells, reaching significance at 10µM (p=0.024) and 100µM (p=0.008) doxorubicin. No significant effect on mean migration distance was observed over time by doxorubicin concentration.

CONCLUSIONS: This tissue-engineered platform allows for a detailed and more faithful characterization of cancer cell behavior within a patient-specific biomimetic breast environment in response to chemotherapeutic agents. Attenuation of the negative doxorubicin effect on percentage tumor migration and potentially cell count within the biomimetic milieu suggests that breast-derived cell constituents may be absorbing/metabolizing the chemotherapeutic agent. Characterization of migratory tumor cell phenotype is important as these cells may be preferentially implicated in metastatic behavior. Further refinement of this platform holds significant promise as a personalized screening tool for modeling breast cancer response to potential therapeutics.

Introduction: In two-stage breast reconstruction, standard practice utilizes acellular dermal matrix (ADM) at the first stage during tissue expander placement. The disadvantages of this approach include infectious complications resulting in TE removal and ADM loss. These complications present a large opportunity-cost requiring not only multiple operations, but also since ADM is expensive. In this study, we compared complication rates in first-stage versus second-stage ADM use in two-stage implant-based breast reconstruction. Our goal was to provide the first cost utility analysis of using acellular dermal matrix at the second stage at the time of expander-implant exchange.

Methods: We retrospectively reviewed patients from August 2021 to December 2024 undergoing two-stage pre-pectoral breast reconstruction. All patients underwent tissue expander placement without ADM during the initial surgery. During the second stage, tissue expanders were replaced with permanent implants using ADM. Primary outcomes were postoperative complications (infection, seroma, hematoma, necrosis, readmissions). Secondary outcomes included infection rates, implant loss, and revisions.

Results: Among 39 patients (71 breasts), 32 underwent bilateral reconstruction and 7 underwent unilateral reconstruction. The average intraoperative tissue expander fill was 250 cc of air and the final expansion expander volume was 550 cc of saline. The implant size range was 210–755 ml. The overall complication rate was 7.0% (n=5 breasts), with infection rate of 5.6% (4 breasts), and 4.2% (3 breasts) rate of implant removal. Seroma and hematoma rates were both 1.4%, with no cases of skin necrosis. Minor complication rates were 2.8% and major complication rates were 4.2%. The average duration of follow-up period was 250 days.

Conclusion: Second-stage ADM in two-stage breast reconstruction shows lower complication rates, particularly for infection and seroma, supporting its potential as a safer, more reliable, and cost-effective alternative to first-stage ADM use.

Purpose

Medical malpractice is a commonly raised claim that nearly all physicians will face at some point during their careers. Plastic surgeons are no exception to this, particularly those performing cosmetic and reconstructive breast surgery. This review aimed to evaluate the outcomes of medical malpractice cases across cosmetic and reconstructive breast surgery and identify common factors leading to litigation.

Methods

PubMed, Web of Science, SCOPUS, Embase, and MEDLINE were queried on October 10, 2024. MeSH terms plastic surgery, breast, malpractice, and related search terms were used without time restriction. Studies that included outcomes of medical malpractice claims filed for cosmetic and reconstructive breast procedures were included. Exclusion criteria included claims outside of the United States, editorials or commentaries, studies without case outcomes, or those not involving medical malpractice. Means across studies were compiled using a simple weighted average based on the number of cases in each study.

Results

Of the 1254 studies queried, 5 studies provided data on medical malpractice claims following cosmetic and reconstructive breast surgeries. These comprised a total of 537 medical malpractice claims filed against plastic surgeons from 1982 to 2020. These included 109 breast reconstruction claims (20.3%), 213 breast reduction claims (39.7%), and 215 cosmetic breast surgeries (40.0%). The most common allegations made by plaintiffs included disfigurement (46.9 - 52.7%), scarring (38.7 - 46.9%), infection (8.6 - 21.6%), and the need for revision surgery (17.2 - 42.5%). Other claims included necrosis, asymmetry, emotional distress, and pain.

426 cases cited specific reasons for plaintiff liability. A total of 746 causes of action were cited in these claims, with the most common being negligence (50.4%), lack of informed consent (25.7%), and failure to diagnose/treat (10.4%). 535 studies included specific case outcomes. Of these, cases were decided in favor of the defendant in 346 instances (64.7%), with the remainder of cases (35.3%) resulting in payment to the plaintiff, either in the form of damages or settlement.

Of cases decided in favor of the plaintiff, financial awards varied significantly. Plaintiff verdicts resulted in a mean damages award across all studies of $538,171 (range: $130,422 - $1,036,469). Settlement amounts had a comparatively narrower range, with a mean of $521,576 (range: $481,055 - $633,960). Of 389 cases with geographic information reported, most cases were litigated in California (18.8%), New York (14.4%), and Florida (10.5%), with relatively fewer cases in Pennsylvania (5.4%), Missouri (4.6%), Texas (3.8%), and Michigan (3.8%).

Conclusion

This review highlights the significant financial and professional risks associated with cosmetic and reconstructive breast litigation. Findings suggest a need for enhanced patient education and shared decision-making, particularly regarding aesthetic outcomes, revision surgeries, and infection prevention strategies to mitigate legal risk. Surgeons practicing in states lacking legal caps on damages awarded to successful plaintiffs in medical malpractice suits such as New York and Florida may be faced with litigation more frequently than those with stricter tort reform, such as Texas and Michigan.

Purpose

Autologous breast reconstruction (ABR) following postmastectomy radiotherapy (PMRT) is often delayed by several months due to the known adverse effects of radiation on reconstructive flaps, however, the optimal time between PMRT and ABR remains uncertain. While it is commonly believed that a longer interval between radiation and reconstruction enhances safety, evidence of this is conflicting. We sought to analyze our institutional data to determine if an optimal timing for autologous breast reconstruction following postmastectomy radiotherapy exists.

Methods

A single-institution retrospective chart review was performed on female patients 18 years and older who underwent abdominally based free flap breast reconstruction from July 2015 to September 2024. Cases were analyzed on a per flap basis and were stratified into 2 groups: one that underwent PMRT and one group that did not. The non-PMRT group served as our control. The PMRT group was then further stratified to 4 cohorts based on the time from PMRT to their ABR. The cohorts were 0-3 months, 3-6 months, 6-12 months, and greater than 12 months. Patient demographics, operative characteristics, hospital length of stay, medical history, and postoperative complication rates were collected. The primary outcomes were major complications: OR take back and flap loss. Secondary outcomes were all other complications including hematoma, seroma, fat necrosis, infection, and dehiscence. Fisher's Exact and Pearson's Chi-squared test were used to detect group differences.

Results

There were a total of 522 flaps amongst 339 patients that met our study criteria. Of these, 191 (36.7%) of the flaps were performed following PMRT: 5 (2.6%) in the 0-3 months cohort, 72 (37.7%) in the 3-6 months, 71 (37.2%) in the 6-12 months, and 43 (22.5%) in the 12+ months cohort. The majority (83%) of all breast were reconstructed using the deep inferior epigastric perforator free flaps. When comparing postoperative outcomes, we found no statistically significant differences between rates of reoperation, flap thrombosis, or flap failure when comparing cases with or without PMRT and no statistically significant differences when comparing cases performed between 0-3 months, 3-6 months, 6-12 months, or 12+ months.

Conclusion

The results of this study suggests that the time between radiotherapy and autologous reconstruction has little effect on the rate of postoperative complications. The lack of differences found in the 0-3 months cohort may be due to an insufficient sample size therefore it may be premature to suggest conclusions about this group. Clinically, this study would point to ABR to be safe as soon as 3 months following PMRT. Further studies and larger sample sizes will allow researchers to better determine the optimal timing of breast reconstruction following PMRT, in particular for those who may undergo reconstruction within 3 months.

Background: Patients with a history of breast augmentation and a new diagnosis of breast cancer face uncertainty surrounding outcomes of breast-conserving therapy (BCT). Surgical complications, poor aesthetic outcomes, and implant issues such as capsular contracture are frequently encountered following radiation treatment and complicate decision making. We aim to review our experience following BCT in patients with prior augmentation. Methods: A single-center, retrospective review was performed of all patients with prior breast augmentation undergoing lumpectomy for a newly diagnosed malignancy. Patients with procedures done from 2007 to 2024 were included, and those with prior mastectomies or lumpectomies on the same site were excluded. We collected demographics, comorbidities, and outcomes data. Results: 65 breasts in 63 patients met inclusion criteria. 52 (80.0%) implants were in the subpectoral plane and 13 (20.0%) were prepectoral. 52 (80.0%) received radiation treatment after their procedure. 43 cases (66.2%) had concurrent sentinel lymph node biopsy and 5 (7.7%) had axillary lymph node dissections. Plastic surgery was consulted preoperatively in 29 cases (44.6%), and 14 (21.5%) cases had plastic surgeons involved in the procedure after tumor removal. Complications included 10 cases of seromas (15.8%), 0 unplanned implant removals, 0 implant infections, 0 unplanned hospitalizations, and 7 cases of new capsular contracture (12.2%) in patients receiving radiation with a mean time first noted of 2.5 years after surgery (range 0.5-4.2 years). Conclusions: With a low rate of complications, BCT is a safe option for patients with augmentation implants. Patients should be informed of the risk of capsular contracture, especially if receiving radiation treatment. Involvement of plastic surgeons can be helpful for procedural planning and optimizing surgical results. Further study of aesthetic and patient satisfaction outcomes following BCT is needed to better guide patient and provider decision making.

Purpose: This study evaluated trends in implant-based breast reconstruction, anticipating a shift in preference toward prepectoral implants-rather than subpectoral or dual-plane-alongside technical advancements addressing complications historically associated with the prepectoral approach. We aimed to correlate changes in technique with clinical outcomes.

Methods: The cohort included adult patients who received implant-based breast reconstruction at the University of Pennsylvania Health System from 2018-2024. Demographic, clinical, operative, and postoperative data were collected. To evaluate trends over time in plane selection, regressions were fitted using percentages of quarterly intervals to reduce noise. Chi-square/Fisher's exact tests were used to compare complications by reconstructive approach; relative risk (RR) was calculated for significant associations.

Results: The study included 670 patients. All cases used either a subpectoral (n = 297) or prepectoral plane (n = 373). Use of prepectoral implants rose significantly across the seven-year study period: according to linear regression, time explained 79.5% of the variance in implant plane selection over quarterly intervals (P = .001), with prepectoral implants increasing from 4.0% of cases in 2018 to an annual peak of 94.2% in 2023 and 89.7% in 2024. Patient clinical characteristics were largely similar between implant planes. Prepectoral implants showed significantly lower incidence of postoperative fat necrosis (RR for prepectoral vs subpectoral: 0.3, 95% CI: 0.1-0.9), native nipple-areolar complex necrosis (RR 0.2, 95% CI: 0.1-0.5), and chronic implant-associated pain (RR 0.4, 95% CI: 0.1-0.8; all P < .05). However, prepectoral implants showed significantly higher incidence of postoperative surgical site infections (RR 3.3, 95% CI: 2.0-5.4), delayed breast healing/dehiscence (RR 1.9, 95% CI: 1.3-2.9), tissue expander loss (RR 2.6, 95% CI: 1.5-4.4), and implant loss (RR 4.8, 95% CI: 1.7-13.8; all P ≤ .001). Prepectoral implants also required significantly higher rates of reoperation due to complications (RR 2.0, 95% CI: 1.4-2.7; P < .001) and readmissions for complications (RR 2.2, 95% CI: 1.2-3.8; P = .005). Acellular dermal matrix use with prepectoral implants did not appear to modify these associations. Stratified analyses generally did not show confounding from reconstruction staging (direct-to-implant vs two-stage, where 20.4% of prepectoral implants were placed directly without prior tissue expanders); differences in prepectoral vs subpectoral complications remained significant, though direct-to-implant prepectoral reconstructions showed the highest incidence of implant loss (19.7% vs 3.1% for two-stage prepectoral, P < .001). Incidence of postoperative cellulitis, seroma, hematoma, mastectomy necrosis, grades III-IV capsular contracture, emergency department visits, or aesthetic revisions did not differ significantly by prepectoral vs subpectoral plane.

Conclusions: This cohort showed a nearly complete reversal of implant plane preference from 2018-2024, with the prepectoral approach supplanting the subpectoral. While prepectoral implants demonstrated lower incidence of necrosis and chronic pain, our cohort showed nearly five times higher risk of prepectoral implant loss along with increased risks of infection, delayed healing, and expander loss, ultimately doubling overall risks of reoperation and readmission compared to subpectoral implants. These results suggest that prepectoral implants may be underperforming, with a complication-driven reoperation rate approaching 30%, warranting further study to determine whether we need to reconsider the prepectoral approach.

Introduction Preference of prepectoral breast reconstruction has progressively surpassed subpectoral placement over the last decade, with most reconstructions being prepectoral.(1-3) However, the impact of reconstruction, including type (immediate with an implant vs. delayed with a TE) and device placement (prepectoral vs. subpectoral) on radiation therapy (RT) planning and dosimetry has not been well described. This study compared RT dosimetry metrics and time to treatment between reconstructed and non-reconstructed cases, and by reconstruction device type and placement.

Methods This single-institution study included 161 patients who underwent mastectomy or lumpectomy followed by RT (2021-2024). Eighty patients had reconstruction (implants: n=29, TEs: n=51); 81 were non-reconstructed. Reconstruction was prepectoral (n=41) or subpectoral (n=39). Radiation outcomes included mean heart dose, lung irradiation, undertreated ("cold spots") and overtreated ("hot spots") areas, plan uniformity (V105/V95), and internal mammary node (IMN) coverage. Additional outcomes included time to RT, IMN omission, TE deflation requests, and skin complications.

Results Patients with subpectoral reconstructions had significantly higher mean heart dose than non-reconstructions (112 vs 85 cGy, p=0.02) but significantly lower percentage radiation to the ipsilateral lung (19% vs 22%, p =0.001). Compared to non-reconstructed cases (1.70), patients with both pre (1.45) and subpectoral reconstructions (1.52) had a lower volume of cold spots (V80/V95, p <0.001). Prepectoral reconstructions had a lower volume of cold spots than subpectoral reconstructions (p=0.03). Results persisted after adjusted analysis. Examining cases where TE vs. implants were present during RT, TE cases had significantly lower cold spots (1.46 vs 1.53, p=0.05) However, these results did not persist after adjusted analysis.
Sub analyses of subpectoral implants (n=20) vs. subpectoral TE (n=19) and prepectoral implants (n=9) vs prepectoral TE (n=32) demonstrated that prepectoral TE had significantly lower cold spots (1.44 vs. 1.53, p=0.02). These results did not persist after adjusted analysis.
The odds of having to drop IMN treatment from a subpectoral radiation plan were about 92% lower than for a prepectoral plan p = 0.007), OR = 0.084 (95% CI: 0.002 – 0.645). The odds of having to drop IMN treatment from a prepectoral plan were about 3.98 times higher than for a non-reconstructed plan (p = 0.02), OR= 3.98 (95% CI: 1.19 – 14.56). Associations persisted after adjusted analysis controlling for treatment laterality and cancer staging.
Groups did not differ significantly in number of plans with adequate IMN coverage (V90%), volume of hot spots or dose uniformity. N=4 (9.8%) of patients with prepectoral TE reconstructions and N=2 (5.1%) of patients with subpectoral TE reconstructions required deflation of the contralateral TE for radiation planning. Time from oncologic surgery to RT and skin findings did not differ significantly according to reconstruction status, device placement or type.

Conclusion Based on the evaluated metrics, the position of chest wall implants/TEs does not significantly impact the radiation treatment plan quality or timing. For patients with prepectoral implants, there may be additional considerations which impact the ability to include the internal mammary nodal chain in the treatment fields. Reconstruction, especially subpectoral, may help minimize lung dose when IMN treatment is needed.

References 1. Seth AK, Sisco M. Prepectoral Breast Reconstruction. Plast Reconstr Surg. 2025;155(1):213e-227e. doi:10.1097/PRS.0000000000011737 2. Copeland-Halperin LR, Lyatskaya Y, Bellon JR, et al. Impact of Prepectoral vs. Subpectoral Tissue Expander Placement on Post-mastectomy Radiation Therapy Delivery: A Retrospective Cohort Study. Plast Reconstr Surg – Glob Open. 2023;11(12):e5434. doi:10.1097/GOX.0000000000005434 3. Sinnott CJ, Pronovost MT, Persing SM, Wu R, Young AO. The Impact of Premastectomy Versus Postmastectomy Radiation Therapy on Outcomes in Prepectoral Implant-Based Breast Reconstruction. Ann Plast Surg. 2021;87(1s Suppl 1):S21-S27. doi:10.1097/SAP.0000000000002801

Background: Implant profile selection significantly impacts aesthetic outcomes in prepectoral direct-to-implant (DTI) breast reconstruction, yet remains poorly understood as a clinical decision point. Despite extensive research on implant cohesivity, critical knowledge gaps exist regarding factors driving profile selection and its influence on surgical techniques and outcomes. This study is the first to systematically evaluate the demographic determinants of profile choice and examines how these decisions affect surgical approach and reconstruction success in DTI reconstruction.

Methods:
A retrospective cohort analysis was conducted on adult female patients who underwent unilateral or bilateral, skin- or nipple-sparing mastectomy with prepectoral DTI breast reconstruction at a s​​ingle, quaternary-referral center between January 2020 and August 2024. Implant profiles were standardized across manufacturers using the projection-to-diameter ratio (pd ratio): low (0.20-0.24), medium low (0.25-0.29), medium (0.30-0.32), medium high (0.33-0.39), high (0.40-0.42), and extra high (≥0.43). Patient demographics, implant characteristics, complications, and reoperation patterns were documented. Multivariable regression identified predictors of profile selection and assessed relationships between profile choice and clinical outcomes.

Results: Among 295 breast reconstructions, implant profile selection exhibited a distinct distribution, with the majority of patients receiving medium high (120, 40.7%) or medium low (89, 30.2%) profiles, followed by medium (62, 21.0%), high (18, 6.1%), low (5, 1.7%), and extra high (1, 0.3%) profiles. Multivariable analysis identified that each unit increase in Body Mass Index (BMI) was associated with a mild but significant increase in the likelihood of choosing a higher-profile implant (OR=1.04, 95% CI=1.01-1.08, p=0.048). Conversely, each year increase in age correlated with lower odds of higher-profile selection (OR=0.90, 95% CI=0.93-0.99, p=0.008). Importantly, among the 100 (33.9%) patients who experienced postoperative complications, including contracture, flipping, and rippling, implant profile demonstrated no statistically significant correlation with the occurrence or type of complications observed. Additionally, among the 72 (24.4%) patients who underwent reoperation, no significant association was found between implant profile selection and reoperation rates. The implant profile type also demonstrated no significant association with the need for implant change during subsequent operations.

Conclusions: Our findings demonstrate clear demographic patterns in implant profile selection, with younger patients, increased BMI, and those with diabetes receiving higher-profile implants. Profile choice is directly associated with the surgical approach but, notably, does not affect complication rates, reoperation risk, or eventual profile changes. Given that profile selection has minimal impact on medical outcomes, this decision should be primarily driven by patient preferences, aesthetic goals, and individual anatomical considerations. These insights emphasize the importance of a shared decision-making process between patients and surgeons, prioritizing patient-specific aesthetic standards while ensuring safe, personalized breast reconstruction outcomes.

Purpose: Infection remains a major complication in implant-based reconstruction following mastectomy, with rates ranging from 2.5% to 24% (1). Traditional prevention strategies, including perioperative antibiotics and antiseptic irrigation, have shown limited success. While prophylactic absorbable antibiotic beads have demonstrated efficacy in orthopedic and trauma settings, their role in implant-based reconstruction remains underexplored. This study evaluates their effectiveness in reducing infection rates, reconstructive loss, and overall outcomes.

Methods: This retrospective cohort study included patients who underwent primary implant-based breast reconstruction with partial subpectoral tissue expanders over a one-year period (January 2024 to December 2024) at a single institution. All patients received a contoured, perforated acellular dermal matrix (ADM), which served as an inferior pole sling. This created a retromuscular pocket.

The experimental group received biodegradable calcium sulfate antibiotic beads (Stimulan ®) infused with 1g vancomycin and 240mg gentamicin in this pocket before tissue expander placement. The inferior border of the pectoralis major was then sewn to the ADM, and two postoperative drains were placed in the prepectoral space. The control group underwent primary partial subpectoral implant-based breast reconstruction with tissue expanders without antibiotic beads over a two-year period at the same institution. Both groups had expanders placed in the same fashion, with ADM and postoperative drains, and received perioperative and post-operative prophylactic antibiotics.

Results: Over a one-year period, 206 patients (353 breasts) underwent implant-based breast reconstruction with prophylactic antibiotic beads, while 113 patients (189 breasts) served as historical controls. The average age was 52.38 years, the mean BMI was 27.12, and the mean mastectomy weight was 570 g. There were no statistically significant differences in age, BMI, or mastectomy weight between groups (p > 0.05, t-test analysis).

The infection rate was 9.35% (33/353) in the antibiotic bead group, significantly lower than 20.11% (38/189) in the control group (p < 0.001, chi-square analysis). Total reconstructive loss was 3.97% (14/353) in the bead group compared to 14.89% (27/189) in the control group (p < 0.001, Fisher's exact test). Among reconstruction losses, 2.27% (8/353) of breasts in the bead group were lost due to infection, compared to 11.64% (22/189) in the control group, while 1.70% (6/353) of bead group breasts were lost due to soft tissue failure. Reoperation for infection was performed in 7.93% (28/353) of total reconstructed breasts, with 20 salvaged with surgical washout (71.43%), 5 salvaged without surgery, and 8 ultimately resulting in reconstruction loss.

Conclusion: Our preliminary results showcased low infection rates and reconstructive loss secondary to infection with utilization of prophylactic antibiotic beads. These findings suggest that the beads may serve as an effective adjunct for infection prevention in breast cancer patients by providing localized antibiotic delivery. However, further studies are needed to confirm their impact.

References: 1. Kenna DM, Irojah BB, Mudge K, Eveler K. Absorbable Antibiotic Beads Prophylaxis in Immediate Breast Reconstruction. Plast Reconstr Surg. 2018;141(4):486e-492e. doi:10.1097/PRS.0000000000004203

Introduction: The incidence rate of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly rising globally and has been strongly associated with textured implant utilization. In 2021, The World Health Organization International Agency for Research on Cancer introduced an International Classification of Diseases in Oncology (ICD-O-3) histology code for anaplastic lymphoma kinase (ALK)-negative ALCL/BIA-ALCL, allowing for the first time, calculation of population-based incidence rates in the US.

Methods: We identified patients newly diagnosed with ALK-negative ALCL/BIA-ALCL in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Database, representing 28% of the US population. Cases were identified if diagnosed in 2021, the first year the ICD-O-3 histology code was implemented. We calculated age-adjusted incidence rates per 100 million persons/year and compared with previous estimates of ALCL and ALCL/T-cell lymphoma, not otherwise specified (T-NOS).

Results: In 2021, there were 9 women diagnosed with ALK-negative ALCL/BIA-ALCL. The incidence rate of ALK-negative ALCL/BIA-ALCL in 2021 was 17.3 (95% CI: 7.7-33.9) per 100 million persons per year. The combined incidence rate of ALK-positive ALCL, ALK-negative ALCL/BIA-ALCL, and T-NOS in 2021 was 23.2 (95% CI: 11.7-41.6). For comparison, the 2020 estimates of ALCL and ALCL/T-NOS were 27.9 (95% CI: 14.9-48.0) and 53.3 (95% CI: 34.4-79.1).

Conclusion: We report the first incidence estimates for ALK-negative ALCL/BIA-ALCL in the US. Use of the ICD-O-3 histology code will enable epidemiological studies to distinguish BIA- from non-BIA-ALCL cases.