Scientific Abstract Presentations: Breast Session 2 Thursday, October 9 Thu, Oct 9 3:30-4:30 p.m. CDT

Background: Post-mastectomy breast reconstruction remains most commonly implant-based. Historically, implants were often placed in a subpectoral pocket. Patients with submuscular implants frequently encounter animation deformity, pain, and cosmetic issues, prompting consideration for removal, exchange, plane change, or autologous reconstruction. Advances in prepectoral reconstruction have prompted many patients to undergo movement of their implants from a submuscular pocket to a prepectoral pocket (a "pocket change"). We aimed to review our institution's experience with this phenomenon. Methods: We conducted a single-center, retrospective review analyzing all patients with prior submuscular breast reconstruction (for post-mastectomy etiology) who underwent pocket change procedures from 2014-2023. We collected data on demographics, comorbidities, and outcomes. Results: Procedures on 277 breasts in 154 patients met inclusion criteria. There were various reasons for pursuing surgery, including: pain/discomfort (173 patients, 63%), animation deformity (158 patients, 57%), cosmetic issues unrelated to animation deformity (94 patients, 34%), muscle spasm (84 patients, 30%), capsular contracture (68 patients, 25%), and implant rupture (44 patients, 16%). 52 cases (19%) involved staged procedures with prepectoral tissue expanders placed before exchange with implants. Of the 277 procedures, mesh was used in 196 of the procedures (71%). Mean length of postoperative follow-up was 2.52 years. Complications included 7 seromas (2.5%), 1 hematoma (0.4%), 10 infections (3.6%), and 7 hospitalizations within 30 days of surgery (2.5%). 6 patients (2.2%) underwent removal of the prepectoral implant within 1 year of surgery-5 due to infection and 1 due to early capsular contracture. 17 (6.1%) of patients encountered at least one of these early complications. 10 cases of capsular contracture were reported (3.6%). Of the 82 patients who provided pain outcome data within 60 days of either a unilateral or bilateral procedure, 74 (90%) reported resolved or significantly improved pain. Conclusions: A pocket change procedure is a safe and effective intervention to treat animation deformity and pain caused by submuscular implants. Further study is warranted to evaluate aesthetic outcomes and patient satisfaction.

Background: Polydioxanone (PDS) mesh is an emerging technology for prosthetic breast reconstruction. However, there is a paucity of data on its safety and efficacy in primary breast reconstruction. Methods: Demographic and outcomes measures from consecutive, immediate prosthetic breast reconstructions using PDS or acellular dermis (ADM) from a single surgeon were evaluated on a per breast basis between 2013-2023. Propensity matching based on demographic variables was conducted. Binary logistic regression analyses were performed to assess the impact of mesh. Results: A total of 796 breast reconstructions were identified, and propensity matching yielded 192 ADM and 48 PDS mesh reconstructions. There was no significant difference with respect to age, ASA status, smoking history, diabetes, mastectomy indication, radiation, chemotherapy, expander plane, and mastectomy type between propensity-matched cohorts. BMI varied by 2.1 points (ADM:25.8 vs. PDS: 23.7, p=0.01). Mean follow-up time was 13.5±2.7 months. The propensity-matched PDS mesh cohort had lower rates of any complication (ADM:23.9% vs. PDS mesh:4.2%, p=0.003), seroma (ADM:11.4% vs. PDS mesh:0%, p=0.01), expander exposure (ADM:12.5% vs. PDS mesh:0%, p=0.01), complication-associated expander removal (ADM:9.9% vs. PDS mesh:0%, p=0.02), and mastectomy flap necrosis (ADM:14.0% vs. PDS mesh:4.2%, p=0.05). PDS mesh, compared to ADM, was independently associated with decreased risk of any complication (OR:0.443, p=0.02), seroma (OR:0.456, p=0.03), expander exposure (OR:0.277, p=0.03), complication-associated expander removal (OR:0.211, p=0.02), and mastectomy flap necrosis (OR:0.12, p=0.04). Conclusion: PDS mesh is an alternative to ADM in primary prosthetic breast reconstruction. Rates of complication-including infection, seroma, and explantation-suggest an acceptable safety profile relative to ADM.

Introduction: Immediate breast reconstruction is generally preferable for breast cancer patients, due to its psychosocial, cost, and logistical benefits. Though, immediate reconstruction has challenges in both implant-based reconstruction (IBR) and autologous breast reconstruction (ABR) (1). Complication rates are variable, with older age and higher body mass index (BMI) identified as risk factors (2). Limited research exists on revision surgeries in immediate reconstruction. This study evaluates complications and revision rates in immediate IBR and DIEP flap reconstruction at two institutions.

Methods: A retrospective review was conducted of all patients who underwent immediate IBR (65 patients, 116 breasts) or ABR with DIEP flaps (158 patients, 158 breasts) following mastectomy between 2018 and 2024 at two medical institutions. Patient demographics, medical history, operative details, complications, and revision surgeries were analyzed.

Results: IBR and ABR patient characteristics were comparable, except for BMI (IBR: 25.46, ABR: 30.75, p<0.001), ptosis grade (p=0.002), and radiation history (IBR: 21.5%, ABR: 44.9%, p=0.002). IBR breasts had significantly lower odds of minor complications (p<0.001, OR 0.22, CI 0.13–0.39) compared to ABR. Further analysis of minor complications showed lower rates of infection (p=0.005, OR 0.26, CI 0.11–0.66) and wound dehiscence (p=0.027, OR 0.39, CI 0.18–0.86) in IBR. No significant differences were observed in major complications, seroma, hematoma, or skin necrosis.

IBR patients were 5.9 times less likely to undergo revision surgery compared to ABR patients (52.3% vs. 71.5%, p<0.001, CI 0.10–0.28). Additionally, IBR patients had 2.5 times lower odds of requiring fat grafting (p=0.003, CI 0.22–0.72) and 5.3 times lower odds of scar revision (p<0.001, CI 0.08–0.44). The total number of revisions was significantly lower in IBR (0.71 per patient) compared to ABR (0.96 per patient) (p<0.001).

Conclusion: Patients undergoing immediate IBR are 83% less likely to require revision surgery compared to those undergoing immediate ABR. While over half of patients required additional procedures, IBR appears to be a more efficient reconstructive option with fewer revisions. Minor complication rates were lower in IBR, while major complication rates were similar between groups. These findings underscore the importance of individualized decision-making in immediate breast reconstruction.

References: 1. Matar, D. Y., Wu, M., Haug, V., Orgill, D. P., & Panayi, A. C. (2022). Surgical complications in immediate and delayed breast reconstruction: A systematic review and meta-analysis. In Journal of Plastic, Reconstructive and Aesthetic Surgery (Vol. 75, Issue 11). https://doi.org/10.1016/j.bjps.2022.08.029 2. Xu, F., Sun, H., Zhang, C., Jiang, H., Guan, S., Wang, X., Wen, B., Li, J., Li, X., Geng, C., & Yin, J. (2018). Comparison of surgical complication between immediate implant and autologous breast reconstruction after mastectomy: A multicenter study of 426 cases. Journal of Surgical Oncology, 118(6). https://doi.org/10.1002/jso.25238

Introduction: Different incision patterns in breast reduction mammoplasty offer distinct advantages and disadvantages. The most commonly used Wise pattern allows for excess lateral skin to be resected but comes with the downsides of a scar that radiates from the nipple-areolar complex to the underside of the breast both laterally and medially.(1,2) The Vertical pattern, the next most widely used technique, creates a smaller, more aesthetically favorable scar but does not allow for adequate resection of excess lateral skin.(1,2) To address this concern, a novel modification to the vertical incision, the Paisley pattern, allows for resection of excess lateral skin, similar to the Wise pattern but without a medial scar – offering a unique advantage over both the Wise and Vertical techniques.(1) This study aims to compare the postoperative outcomes of bilateral breast reduction mammoplasty utilizing the Paisley Pattern skin resection versus the more commonly used Wise and Vertical patterns.

Methods: A retrospective chart review was conducted at Regional One Health including patients aged 18 years and older who underwent a bilateral breast reduction mammoplasty between January 2020 and November 2024. Measurements included demographics, comorbidities, surgical incision technique, body mass index (BMI), and postoperative complications. 60-day postoperative complications were recorded and include seroma, hematoma, wound dehiscence, infection, and revision surgeries.

Results: In the study time frame, 118 patients underwent bilateral breast reduction mammoplasty. The average BMI of patients in this study was 33. 60 (58%) were resected using the Wise technique, 44 (37%) were resected using the Vertical surgical incision technique, and 14 (12%) using the Paisley technique. Of this cohort there were 9 reoperations, 4 of which were revisions related to patient dissatisfaction. The Paisley and Wise technique resulted in 0 revisions, whereas the Vertical technique results in 1. There were 28 patients with reported complications within this cohort, with a 36.4% complication rate for the Vertical technique, 21.4% for the Paisley technique, and 14.8% for the Wise technique. Between the surgical techniques there was no significant difference in rate of complications or rate of reoperation. Rates of complications between BMI were not considered statistically significant. The operating time varied between techniques, the Paisley technique averaged 2.47 hours, the Vertical technique averaged 3.05 hours, and Wise averaged 4.71 hours. The difference between Paisley and Vertical techniques' operative time was not statistically significant (p=0.152), however the operative time between Paisley and Wise as well as wise compared to Vertical were considered significant (p<0.001).

Conclusions: When used for bilateral breast reduction mammoplasty, the Paisley Pattern skin resection had comparable postoperative outcomes to the Wise and Vertical patterns. Shorter operative time as well as a trend towards fewer complications and reoperations holds implications for broader technique adoption.

References: 1. Becker DB. The Paisley Pattern Breast Reduction. Plast Surg (Oakv). 2019;27(2):189-194. doi:10.1177/2292550319828797 2. Greco R, Noone B. Evidence-Based Medicine: Reduction Mammaplasty. Plast Reconstr Surg. 2017;139(1):230e-239e. doi:10.1097/PRS.0000000000002856

Purpose: Skin necrosis is a common complication following mastectomy, with reported incidence rates as high as 30% (1). Our previous studies in rodent models demonstrated that topical tacrolimus significantly reduces skin flap necrosis and outperforms other studied topicals (2-3), but its use in human ischemic skin has yet to be described. This study aims to introduce topical tacrolimus as an effective adjunctive treatment for skin necrosis after immediate breast reconstruction.

Methods: A retrospective review was conducted on patients after mastectomy with immediate tissue expander breast reconstruction between October 2023 and December 2024. Patients deemed at risk for skin ischemia, by either gross observation or abnormal indocyanine green angiography findings, were prescribed topical tacrolimus and instructed to apply twice a day. Patient demographics, medication timelines, surgical details, complications, and clinical outcomes were analyzed using descriptive statistics.

Results: 15 patients (n= 20 breasts) were analyzed. The mean age and BMI were 55.20± 3.31 and 22.53±0.71 respectively. The average length of tacrolimus usage was 18.85±2.63 days. Of all at-risk breasts, only one breast developed full-thickness necrosis, resulting in a 95% salvage rate. Necrosis was completely prevented in ten breasts (50.0%). All patients were able to continue their scheduled breast cancer treatment and reconstruction without any significant delays. No adverse effects related to topical tacrolimus use were reported by all patients.

Conclusion: This study demonstrates that topical tacrolimus is a safe and effective strategy for preventing full-thickness necrosis in threatened mastectomy flaps. These promising results should be followed up with a randomized control trial to determine the efficacy of topical tacrolimus in treatment for mastectomy flap necrosis.

References: 1. Nykiel M, Sayid Z, Wong R, Lee GK. Management of mastectomy skin flap necrosis in autologous breast reconstruction. Ann Plast Surg. 2014;72 Suppl 1:S31-S34. doi:10.1097/SAP.0000000000000174 2. Jung W, Van Y vu R, Huang H, Wald G, Otterburn DM. The Effect of Pre-and Postsurgical Topical Tacrolimus on Pedicled Flap Survival in Rats: A Pilot Study. Plastic and Reconstructive Surgery Global Open. 2021;9(10 Suppl). 3. Wald G, Van YV, Towne W, Otterburn DM. The Effect of Topical Tacrolimus on Pedicled Flap Survival: A Histological Analysis. Ann Plast Surg. 2021;87(1s):S57-S59. doi:10.1097/SAP.0000000000002799

Purpose: Skin necrosis is a common complication following mastectomy, with reported incidence rates as high as 30% (1). Our previous studies in rodent models demonstrated that topical tacrolimus significantly reduces skin flap necrosis and outperforms other studied topicals (2-3), but its use in human ischemic skin has yet to be described. This study aims to introduce topical tacrolimus as an effective adjunctive treatment for skin necrosis after immediate breast reconstruction.

Methods: A retrospective review was conducted on patients after mastectomy with immediate tissue expander breast reconstruction between October 2023 and December 2024. Patients deemed at risk for skin ischemia, by either gross observation or abnormal indocyanine green angiography findings, were prescribed topical tacrolimus and instructed to apply twice a day. Patient demographics, medication timelines, surgical details, complications, and clinical outcomes were analyzed using descriptive statistics.

Results: 15 patients (n= 20 breasts) were analyzed. The mean age and BMI were 55.20± 3.31 and 22.53±0.71 respectively. The average length of tacrolimus usage was 18.85±2.63 days. Of all at-risk breasts, only one breast developed full-thickness necrosis, resulting in a 95% salvage rate. Necrosis was completely prevented in ten breasts (50.0%). All patients were able to continue their scheduled breast cancer treatment and reconstruction without any significant delays. No adverse effects related to topical tacrolimus use were reported by all patients.

Conclusion: This study demonstrates that topical tacrolimus is a safe and effective strategy for preventing full-thickness necrosis in threatened mastectomy flaps. These promising results should be followed up with a randomized control trial to determine the efficacy of topical tacrolimus in treatment for mastectomy flap necrosis.

References: 1. Nykiel M, Sayid Z, Wong R, Lee GK. Management of mastectomy skin flap necrosis in autologous breast reconstruction. Ann Plast Surg. 2014;72 Suppl 1:S31-S34. doi:10.1097/SAP.0000000000000174 2. Jung W, Van Y vu R, Huang H, Wald G, Otterburn DM. The Effect of Pre-and Postsurgical Topical Tacrolimus on Pedicled Flap Survival in Rats: A Pilot Study. Plastic and Reconstructive Surgery Global Open. 2021;9(10 Suppl). 3. Wald G, Van YV, Towne W, Otterburn DM. The Effect of Topical Tacrolimus on Pedicled Flap Survival: A Histological Analysis. Ann Plast Surg. 2021;87(1s):S57-S59. doi:10.1097/SAP.0000000000002799

Background Breast implant illness (BII) refers to a set of nonspecific systemic symptoms including fatigue, joint pain, anxiety, cognitive dysfunction, rash, and weight changes reported by some patients with breast implants. Although BII lacks formal diagnostic criteria and is not universally recognized, public awareness has grown, with some individuals undergoing explantation in hopes of symptom relief. Existing studies offer mixed findings-while explantation can alleviate symptoms for some, others report persistent issues, suggesting multifactorial mechanisms. Given limited epidemiological data on BII-compatible symptoms, especially when comparing different reconstructive approaches, this retrospective cohort study utilized the TriNetX federated global network to evaluate the incidence of these symptoms in mastectomy patients who underwent autologous reconstruction, implant-based reconstruction, or no reconstruction.

Methods We queried TriNetX for women aged ≥18 years diagnosed with breast cancer between 2005 and 2025 who had a mastectomy with or without reconstruction. Patients with pre-existing BII-compatible symptoms or with non-breast malignancies were excluded. Three cohorts were defined: no reconstruction, autologous reconstruction, and implant-based reconstruction. BII-compatible symptoms outlined by the FDA-fatigue, joint pain, anxiety, cognitive dysfunction, autoimmune disease, hair loss, depression, rash, headache, and abnormal weight changes-were identified via ICD-10 codes between 3–30 years post-surgery. 1:1 Propensity score matching was performed for age, race, receptor status, TNM stage, BMI, diabetes, hypertension, and hyperlipidemia. Risk ratios (RR) with 95% confidence intervals assessed differences in symptom incidence.

Results After matching, 3,854 patients were included in the implant vs. autologous comparison, 6,990 in autologous vs. no reconstruction, and 4,380 in implant vs. no reconstruction. Compared to no reconstruction, autologous reconstruction had significantly higher risks of fatigue (RR=1.406; p=0.006), joint pain (RR=1.287; p=0.004), cognitive dysfunction (RR=2.089; p=0.040), and abnormal weight gain (RR=2.701; p=0.001). There were no significant differences between implant-based and autologous groups. When implant-based reconstruction was compared to no reconstruction, the implant group showed a lower risk of fatigue (RR=0.663; p=0.007) and rash (RR=0.611; p=0.041). All other symptoms, including anxiety, depression, headache, hair loss, and other weight changes, did not differ significantly.

Conclusions In this analysis, autologous reconstruction was linked to higher rates of certain BII-like symptoms compared to no reconstruction, whereas implant-based reconstruction posed no additional risk relative to autologous and was associated with fewer symptoms than no reconstruction. These findings imply that factors such as surgical complexity, psychosocial stress, or comorbidities may underlie postoperative systemic symptoms. Cancer patients may also experience heightened surveillance, health anxiety, or somatic complaints, prompting further research. Prospective investigations with standardized patient-reported outcomes, extended follow-up, and psychosocial assessments are needed to clarify BII pathophysiology, refine diagnostic criteria, and determine whether these symptoms arise from inflammatory or psychological origins. Ultimately, standardized definitions and diagnostic pathways may reduce confusion and support evidence-based counseling for patients considering or undergoing reconstruction.

Title: Second Stage Mastopexy Following Nipple-Sparing Mastectomy in Implant and Autologous-Based Breast Reconstruction

Authors: Ricardo Gomez, Michael Mazarei, Nicholas Lombana MD, Irene Ma MD, Michel Saint Cyr MD

Introduction: Dermal pedicle flaps and immediate mastopexy certainly are powerful tools at the first stage of the reconstruction in selected patients with excellent vascularity to the mastectomy skin flaps, small to moderate sized breasts, thick mastectomy skin flaps, and minimal comorbidities. Nevertheless, many patients are not candidates for immediate mastopexy and are better served by performing this at the second stage of their reconstruction. In this article, we describe the 2-stage surgical technique that has been used by the senior for all his primary tissue-expander based breast reconstruction. Our goal was to compare mastopexy volume, rate of NAC malposition, and necrosis in first versus second stage mastopexy.

Methods: A retrospective review of NSM patients undergoing two-stage reconstruction from 2021 to 2024 was conducted. This included a total of 150 patients. We assessed NAC positioning, complication rates, and the impact of mastopexy techniques (periareolar vs. inverted-T). Fat grafting was performed in all implant-based reconstructions. Data included implant size, flap type, and adjunctive procedures such as capsulorrhaphy.

Results: 150 patients (242 breasts) with average age of 51.2 ± 3.8 years old underwent mastopexy at the second stage of reconstruction. The mean weight of the excised breast tissue was 575 ± 120 grams. The overall complication rate was 8%. There was one case of complete nipple necrosis. There were no cases of flap loss. Asymmetry of the NAC was present in 8% of the groups.

Conclusion: Our results compare very favorably to historical mastopexy results in cosmetic surgery and are relatively much lower than reports when performed at the time of initial reconstruction and mastectomy. The striking result of this series is that NAC was able to be positioned in the correct normal Pitanguy's point position in phase two despite having grade two or greater ptosis at the initial reconstruction This study supports second-stage mastopexy as a safe and effective method to enhance reconstructive outcomes after NSM, particularly when combined with fat grafting and pre-pectoral implant placement.

Purpose: Predicting short-term postoperative complications after breast reconstruction is critical for improving patient outcomes and reducing healthcare costs. This study aimed to investigate the utility of machine learning algorithms to predict 30-day readmission, 30-day reoperation and prolonged length of stay in patients undergoing breast reconstruction.

Methods: Data was collected from patients who underwent autologous, implant, and tissue expander-based reconstruction in the National Surgical Quality Improvement Program (NSQIP) database (2020-2022). Six machine learning algorithms (XGBoost, LightGBM, Random Forest, AdaBoost, logistic regression, and a neural network) were trained to predict 30-day readmission, 30-day reoperation and prolonged length of stay. Model performance was assessed using area under the receiver operating characteristic curve, sensitivity, specificity, and Brier score. SHapley Additive exPlanations (SHAP) values ranked predictors influencing model outcomes.

Results: A total of 27,718 patients (5,584 autologous; 8,170 implant; 13,964 TE) were included. Top-performing machine learning models showed moderate to strong predictive performance across cohorts for 30-day reoperation, 30-day readmission, and prolonged length of stay, with AUCs ranging from 0.614 to 0.861. The highest AUCs were achieved for prolonged length of stay in the implant cohort (AUC 0.861) and for 30-day readmission in the delayed autologous cohort (AUC 0.859). Key predictors of reconstructive complications included operative time, BMI, age, reconstruction timing, and ASA class.

Conclusion: Machine learning can predict short-term postoperative outcomes in breast reconstruction patients. With further model refinement and data quality optimization, these models may improve preoperative risk-stratification and patient outcomes in breast reconstruction.

Background: Implant-based breast reconstruction (IBBR) is increasingly utilized by plastic surgeons. Continued challenges in IBBR include limited expander/implant coverage and frequent complications. Improved coverage is tackled with biological meshes and dermal flaps though their comparative improvement in complications is limited; thus, some surgeons combine these tools. The purpose of this study was to evaluate clinical outcomes of IBBR using acellular dermal matrix (ADM) alone versus ADM combined with adipodermal flaps (ADF) across multiple medical centers.

Methods: We identified 382 patients who received IBBR with implants or tissue expanders after mastectomy at two Atrium Health medical centers between January 2018 and July 2024. Data on patient demographics, preoperative ptosis grade, and body mass index (BMI) was retrospectively collected. Clinical outcomes including seroma, hematoma, infections, and necrosis were categorized as either major complications or minor complications based on whether they required return to the operating room.

Results: Of the 643 reconstructions, 580 used ADM alone and 63 used ADM with ADF. Patients who received ADM with ADF had higher BMIs (p<0.001). The ADM with ADF cohort had higher grades of preoperative ptosis (p<.001). The ADM with ADF cohort had 1.87 times the odds of major complications compared to the ADM cohort, though not statistically significant (p=0.243). Similarly, there were no differences in the odds of overall complications, minor complications, or revisions (p=.325, p=.321, p=0.09). Notably, in patients with grade III ptosis, there was a significantly higher rate of major complications in the ADM with ADF cohort (20.9% vs 8.0%; p=0.046).

Conclusions: Previous studies found similar aesthetic outcomes and complication rates when comparing IBBR with ADM versus no ADM and ADM versus ADF (1,2). We find that adding ADF to IBBR with ADM provides no significant change in risk of complications. When taken into consideration with previous findings that ADM alone versus ADF alone do not have significant differences in complications, we support the conclusion that opting for ADF alone might be a more cost-effective approach to IBBR without a significant increase in complication risk (3). Previous studies have not explored other patient factors, aside from BMI, that may influence the outcomes of different reconstructive aids. Here, we identify ptosis as a possible predictor of increased complication risk though more research is needed.

References:
1. Lohmander F, Lagergren J, Johansson H, Roy PG, Brandberg Y, Frisell J. Effect of Immediate Implant-Based Breast Reconstruction After Mastectomy With and Without Acellular Dermal Matrix Among Women With Breast Cancer: A Randomized Clinical Trial. JAMA Netw Open. 2021 Oct 1;4(10):e2127806. doi:10.1001/jamanetworkopen.2021.27806

2. Hon HH, Mubang RN, Wernick BD, Freedman SF, Stoltzfus JC, Miele LF, Stawicki SP, Morrissey WM Jr. Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost. Plast Reconstr Surg Glob Open. 2017 Jun 28;5(6):e1382. doi: 10.1097/GOX.0000000000001382.

3. Mata Ribeiro L, Meireles RP, Brito IM, Costa PM, Rebelo MA, Barbosa RF, Choupina MP, Pinho CJ, Ribeiro MP. Comparison of Outcomes in Immediate Implant-Based Breast Reconstruction: Acellular Dermal Matrix versus Inferior Dermal Flap. Arch Plast Surg. 2022 Apr 6;49(2):158-165. doi: 10.1055/s-0042-1744404.

Introduction: Tissue expander-based breast reconstruction commonly relies on opioids for postoperative pain management, but opioid use is associated with significant adverse effects, including nausea, sedation, constipation, and the potential for dependence. With the increasing adoption of Enhanced Recovery After Surgery (ERAS) protocols, multimodal pain management strategies have been developed to minimize opioid consumption. Liposomal bupivacaine (Exparel) provides prolonged analgesia for 48-72 hours, potentially reducing postoperative opioid requirements compared to traditional bupivacaine (Marcaine), which has a duration of only 6-8 hours. This study evaluates whether Exparel regional blocks reduce opioid consumption in patients undergoing breast reconstruction with tissue expander placement compared to Marcaine.

Methods: A retrospective cohort study was conducted using medical records from January 2019 to June 2022 across multiple institutions. Patients undergoing tissue expander-based breast reconstruction with either Exparel or Marcaine administered via PECs 1, PECs 2, and serratus anterior blocks were included. Opioid prescriptions were confirmed through the New York Prescription Monitoring Program (PMD) and converted into morphine equivalent doses (MED) for comparison. Exclusion criteria included patients with chronic pain, pre-existing opioid use, or incomplete PMD documentation. Primary outcomes included total opioid consumption (MED), number of opioid prescriptions, and differences in opioid type usage between the two cohorts. Statistical analysis included Chi-square tests, ANOVA, and Tukey's Honestly Significant Difference tests, with a significance threshold of p<0.05.

Results: A total of 163 patients were analyzed (42 Marcaine, 121 Exparel). The mean age was 53.8 years, with 57 unilateral and 106 bilateral reconstructions. Groups did not differ significantly by age, laterality of reconstruction, or timing of tissue expander placement, though the Exparel group had a significantly higher proportion of sub-pectoral tissue expander placements (p<0.05). The Exparel group had significantly lower opioid consumption, with a mean MED of 97.2 ± 81.8 compared to 160.5 ± 150.6 in the Marcaine group (p<0.005). Additionally, patients receiving Exparel had fewer total opioid prescriptions (p<0.05). When analyzing opioid type, patients in the Exparel cohort who were prescribed Percocet or Oxycodone (alone or in combination) had significantly lower MED and total opioid prescriptions compared to the Marcaine group (p<0.05). However, there was no significant difference in Tramadol use between cohorts, suggesting that patients receiving Tramadol may represent a subgroup with a higher baseline opioid requirement. Patients prescribed multiple opioid types (e.g., Percocet + Tramadol or Percocet + Oxycodone) had higher MED and total opioid prescriptions than those prescribed a single opioid type (p<0.05), emphasizing the impact of combination opioid therapy on overall consumption.

Conclusion: The use of Exparel regional blocks significantly reduces postoperative opioid consumption and total opioid prescriptions following tissue expander-based breast reconstruction compared to Marcaine. This is likely due to Exparel's extended analgesic effect during the critical early postoperative period, when pain is most severe. These findings align with previous studies demonstrating the efficacy of Exparel in reducing opioid use across various surgical procedures. While Exparel offers improved pain control and opioid reduction benefits, its higher cost remains a consideration. Future prospective, multi-institutional studies with larger patient populations are needed to further validate these findings and assess the cost-effectiveness of Exparel in routine breast reconstruction protocols.