Scientific Abstract Presentations: Breast Session 3 Thursday, October 9 Thu, Oct 9 5:00-6:00 p.m. CDT

Background: Safety-net hospitals care for underserved populations, often treating many publicly insured and uninsured patients with complex comorbidities. As a results, surgical outcomes at these facilities are often worse compared to other institutions [1][2]. With the increasing prevalence of post-mastectomy implant-based reconstruction, more overweight and obese women are seeking breast reconstruction. Although obesity is a known risk factor for postoperative complications with breast reconstruction, most studies rely on large databases, limiting focus on safety-net populations, which may be more vulnerable [3][4]. This study assessed the safety and risk of post-mastectomy implant-based reconstruction in obese patients at a safety-net hospital.

Methods: A retrospective review was conducted on patients who underwent mastectomy with implant-based reconstruction between February 2010 and June 2024 at a Los Angeles safety-net hospital. Patients with less than three months of follow-up were excluded. Remaining patients were stratified into nonobese (BMI = 20 to 29.9 kg/m2) and obese (BMI > 30 kg/m2) groups. The Area Deprivation Index (ADI) was calculated for each patient to assess socioeconomic status [5]. Rates of postoperative implant complications (including mastectomy flap necrosis, infection, implant exposure, implant loss, implant exchange, seroma, and wound dehiscence), infection, and unplanned reoperations were collected. Demographics and risk factors for complications were considered. Statistical analyses included Chi-Squared and Fisher's exact tests for categorical variables and Kruskal-Wallis test for continuous variables. A multivariable regression analysis controlled for differences between the nonobese and obese cohorts.

Results: During the study period, 101 patients met inclusion criteria, yielding 158 breast reconstructions. In total, 56% were Spanish-speaking and 68% of Latinx/Hispanic ethnicity. The majority (93%) were covered by public insurance and 7% were uninsured or self-pay. Mean (range) ADI was 6 (1-9). Most patients (92%) were treated with tissue expander, while 7.9% received direct to implant reconstruction. The prevalence of obesity was 27.7%, with 17.8% defined as class I obese (BMI = 30 to 34.9 kg/m2), 5.9% defined as class II obese (BMI = 35 to 39.9 kg/m2), and 3.9% defined as class III obese (BMI > 40 kg/m2). Compared to nonobese patients, the obese groups had a higher prevalence of hypertension (p=0.02). No significant differences in other risk factors were identified, including diabetes mellitus, positive smoking history, perioperative chemotherapy, and perioperative radiotherapy (p>0.05). Obese patients (BMI >30 kg/m2) had significantly higher rates of all-cause implant complications (p=0.045), unplanned reoperation (p=0.036), tissue expander removal (p=0.001), and infections (p=0.004). Most (34.6%) unplanned reoperations were for tissue expander removal, followed by excision of necrosed skin (19.2%) and implant removal for infection (11.5%). Median time to unplanned reoperation was 3.45 months (IQR 1.18-9.89 months), with similar durations across BMI groups (p=0.53). Seven patients (6.9%) were readmitted within 30 days, with no significant difference between groups (p=0.09). On logistic regression controlling for hypertension, obesity remained a predictor of infection (OR=3.79, 95% CI: 1.26-11.37, p=0.017).

Conclusion: Obesity was associated with higher risks for complications in implant-based breast reconstruction, specifically infection. Further studies should focus on further delineating the relationship between severity of obesity and breast implant complications.

References: 1. Mouch CA, Regenbogen SE, Revels SL, Wong SL, Lemak CH, Morris AM. The quality of surgical care in safety net hospitals: a systematic review. Surgery. 2014;155(5):826-838. doi:10.1016/j.surg.2013.12.006 2. Hong Y, Zheng C, Hechenbleikner E, Johnson LB, Shara N, Al-Refaie WB. Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the Unintended Consequences of the Patient Protection and Affordable Care Act. J Am Coll Surg. 2016;223(1):142-151. doi:10.1016/j.jamcollsurg.2016.04.042 3. Taghioff SM, Slavin BR, Mehra S, Holton T, Singh D. Risk stratification of surgical-site outcomes by BMI and flap type in autologous breast reconstruction. J Plast Reconstr Aesthet Surg. 2023;80:115-125. doi:10.1016/j.bjps.2023.01.042 4. Fischer JP, Cleveland EC, Nelson JA, et al. Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 National Surgical Quality Improvement Program data sets. Plast Reconstr Surg. 2013;132(4):750-761. doi:10.1097/PRS.0b013e31829fe33c 5. Kind AJH, Buckingham WR. Making Neighborhood-Disadvantage Metrics Accessible - The Neighborhood Atlas. N Engl J Med. 2018;378(26):2456-2458. doi:10.1056/NEJMp1802313

Background: Microvascular breast reconstruction exhibits high levels of patient satisfaction but is performed far less often than implant-based reconstruction (1). Underpayment of free flap reconstruction is thought to contribute to this trend (2). Previous studies have characterized compensation disparities between the two reconstruction types by measuring 1) work relative value units (wRVUs) per hour, 2) claims-based reimbursement per wRVU, and 3) theoretical CMS-based reimbursement per hour (3-5). This study re-explores compensation disparities between implant-based and free flap reconstruction, using real-world collections and operative times data to calculate an effective hourly reimbursement rate.

Methods: The PearlDiver multi-payer claims database was queried from 2017-2022 for records matching immediate implant (CPT-19340), delayed implant (CPT-19342), tissue expander (CPT-19357), free flap (CPT-19364), or DIEP flap (S2068) operations. Individual claims were included if they represented an operation performed by a plastic surgeon, had non-zero reimbursement, and did not co-list mastectomy-related CPT codes. The National Surgical Quality Improvement Program (NSQIP) database was queried from 2017-2022 to obtain operative time data from records with parallel inclusion criteria. Median collections were divided by median operative time to establish an effective hourly reimbursement rate. Differences between groups were analyzed via Kruskal-Wallis and Mann-Whitney tests.

Results: Median per-operation reimbursements for immediate implant, delayed implant, tissue expander, free flap, and DIEP flap were $2,538, $2,245, $3,316, $8,265, and $16,363, respectively (p<0.01). Median operative times for delayed implant (19342), tissue expander (19357), and free flap (19364) were 89.0, 93.0, and 450.0 minutes, respectively (p<0.01). The overall 2017-2022 median hourly reimbursement rates for immediate implant, delayed implant, tissue expander, free flap, and DIEP flap were $1,711/hr, $1,513/hr, $2,139/hr, $1,102/hr, and $2,218/hr, respectively. Each group earned significantly greater reimbursements from non-CMS than CMS payers (p<0.01). For each group, median per-operation reimbursements were greater in inpatient than outpatient settings; however, outpatient operations earned greater hourly rates due to significantly reduced operative times (p<0.01).

Conclusions: By leveraging claims data, our study captures a broader array of factors impacting real-world reimbursement than are reflected by wRVU- or CMS-based estimates alone. By standardizing reimbursement according to operative time, we enable direct comparison between reconstruction groups. The data show compensation disparities between implant-based and free flap reconstruction, including a two-fold difference in hourly reimbursement between tissue expander and free flap groups. These trends may arise from differences in commercial insurance negotiations and variable usages of inpatient versus outpatient settings. Without intervention, reimbursement disparities may insufficiently incentivize the growth of microvascular reconstruction techniques.

References: 1. Panchal H, Matros E. Trends in postmastectomy breast reconstruction. Plast Reconstr Surg. 2017;140(5S):7S-13S. 2. Panchal H, Shamsunder M, Sheinin A, et al. Physician payments and microvascular breast reconstruction. Plast Reconstr Surg. 2020;145(2):333-339. 3. Cadwell JB, Ahsanuddin S, Patel S, et al. RVUs and operative time in plastic surgery. J Plast Reconstr Aesthet Surg. 2022;75(7):2286-2292. 4. De la Fuente Hagopian A, Farhat S, Reddy NK, et al. Reimbursement in reconstructive vs. aesthetic surgery. Plast Reconstr Surg Glob Open. 2024;12(11):e6313. 5. Shamsunder MG, Sheckter CC, Sheinin A, et al. Payment variation for microsurgical reconstruction. Plast Reconstr Surg. 2021;147(3):505-513.

Options for breast reconstruction with implants continue to evolve. Increasingly implants are placed in the prepectoral space to avoid added discomfort from muscle elevation which leads to less animation deformity, less pain, and swifter recovery. In addition, the direct-to-implant approach bypasses tissue expander placement completely in select patients, which diminishes the complications associated with additional surgery (expander implant exchange) and improves patient satisfaction. Because of the surgical dissection involved with a mastectomy however, direct-to-implant reconstruction often requires mesh to control implant position to maximize the aesthetic result.

 There are a variety of meshes available to address clinical scenarios that require soft tissue support, such as controlling implant position in direct-to-implant breast reconstruction.  This series examined the efficacy of Durasorb mesh, a polydioxanone mesh that is FDA approved and a relatively new addition to the existing meshes available for use in reconstructive and aesthetic breast surgery.   Durasorb provides for structural support of the implant at the time of placement but is more biocompatible than other mesh options. Durasorb degrades and disappears over time and appears to lead to less seromas, chronic inflammation, and minimal long-term foreign body reactions.  This abstract details the results of a single surgeon's use of Durasorb in direct-to-implant breast reconstruction over a 30 month period.

Seventy-eight patients had direct-to-implant breast reconstruction in the prepectoral space over the study period.   Sixty-two patients had bilateral reconstruction, and sixteen patients had unilateral reconstruction for a total of 140 distinct surgical sites.  Intraoperative fluoroscopic imaging of all mastectomy flaps was used at the time of implant placement in all DTI patients which lowers the likelihood mastectomy flap necrosis and implant exposure.  No patient spent more than one night in the hospital, and as the study progressed, more patients were sent home the same day.  Of the 140 implants placed, four implants became infected and had to be removed (3% of the total placed).   An additional three patients had their implants removed or exchanged because of mastectomy skin necrosis, including one patient who presented nine months after reconstruction with lower pole skin necrosis without infection.  At the time of this abstract review, approximately 20% of patients had additional elective procedures such as fat grafting or implant exchanges postoperatively during the study period for a variety of aesthetic and symmetry reasons. 

This study demonstrates the safety and effectiveness of Durasorb mesh in immediate direct-to-implant breast reconstruction.  In selected patients this study negates the additional cost and risk of first stage tissue expander breast reconstruction.  Patients are out of the hospital quicker and throughout the study period an increasing percentage of patients had their mastectomies and direct-to-implant reconstructions as outpatients.  The results of this series suggests that Durasorb mesh may deliver superior results in direct-to-implant breast reconstruction in select patients with lower overall cost, shorter hospitalizations, and diminished short term complications based on prior studies and less long term foreign body reactions.

Background: Tissue expander (TE) infections are a significant concern in breast reconstruction, leading to increased morbidity, extended treatment durations, potential loss of the expander, and delays in final reconstructive procedures. Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA), are frequently implicated pathogens in these infections. Consequently, preoperative nasal swabbing and decolonization protocols have been implemented to mitigate infection risks associated with these organisms. However, a standardized, universally accepted protocol for infection prevention remains elusive. This study evaluates the impact of preoperative S. aureus and MRSA screening on TE-related infections.

Methods: A retrospective chart review was conducted, encompassing 151 TEs implanted in 93 patients at a single institution. Preoperative screening for S. aureus and MRSA was performed, with results confirmed prior to surgical intervention. Patients identified as carriers received appropriate decolonization treatment. The primary outcome measured was the incidence of TE infections necessitating premature removal. All statistical analyses, including student T-tests, were performed using R software (v.4.2.0).

Results: Of 93 patients, 50 received pre-operative screening. S. aureus was identified in 9/50 (18%) and MRSA in 1/50 (2%), and appropriately treated. Of 151 TEs placed, 16 (10.6%) were prematurely removed due to infection concern. 9/16 (56%) were culture-positive with 1 growing skin flora (C. acnes). 5/8 (62.5%) of the remaining culture-positive infections grew P. aeruginosa, while 2/8 (25%) grew S. marcescens. One patient's culture grew MRSA, but notably, this patient was neither S. aureus nor MRSA-positive prior to TE placement. There were no significant differences in days from implantation (p=0.85) or days from the last fill (p=0.66) to first noted infection between TEs with and without culture growth.

Conclusions: Pre-operative screening and decolonization for S. aureus and MRSA alone may not sufficiently reduce the incidence of TE infections, given the prevalence of infections caused by other pathogens. Our findings further suggest that infection risk may be driven more by bacterial colonization, host susceptibility, and procedural factors rather than the timing of implantation or expansions. A more comprehensive infection control strategy should be considered to address the diversity of infectious agents with attention to institution-specific microbial factors. Further research is warranted to develop and validate effective preventive measures tailored to the specific risk factors and microbial profiles associated with breast reconstruction procedures.

Background: Implant-based breast reconstruction (IBBR) may be performed immediately at the time of mastectomy, within 28 days for ischemic preconditioning (vascular delay reconstruction, VDR), or more than 28 days after mastectomy (delayed reconstruction) (1). Immediate reconstruction (IR) is often favored due to its psychological benefits, preservation of the native breast envelope, and its cost-effectiveness by reducing operating time and hospital stays (2). However, some surgeons opt for VDR to optimize mastectomy flap perfusion. While the literature does not often distinguish between VDR and delayed reconstruction, it is noted that patients with higher BMIs, smoking history, and prior radiation may be more likely to undergo delayed reconstruction (3).

Objective: This study aimed to analyze patient characteristics in IR versus VDR groups and assess whether factors such as BMI, smoking history, and prior radiation can help predict optimal reconstructive timing. Additionally, ischemic complication rates were compared in IR versus VDR breasts.

Methods: Patients who underwent IBBR between 2018 and 2024 with at least 6 months of follow-up were identified. A retrospective chart review was performed, and statistical analysis was conducted using chi-squared tests, t-tests, and Fisher's exact tests to compare BMI, smoking history, radiation history, and complication rates between IR and VDR groups.

Results: A total of 384 IBBR cases met the inclusion criteria, comprising 318 IR and 66 VDR cases. The average BMI in the IR group was 27.7 ± 6.7 compared to 26.3 ± 4.9 in the VDR group (p-value = 0.057). Ninety (28.3%) patients in the IR group were current or previous smokers compared to 15 (22.8%) in the VDR group (p-value = 0.728). Seventy-five (23.6%) patients in the IR group had prior radiation history compared to 12 (18.2%) in the VDR group (p-value = 0.338). There was a total of 22 (4.2%) ischemic complications in the IR group when considering all reconstructed breasts (n = 528) compared to 5 (4.6%) in the VDR group (n = 110) (p-value = 0.797).

Conclusion: BMI, smoking history, and prior radiation history showed no significant differences between the IR and VDR groups. This suggests low utility using these factors to predict the need for VDR. The decision is likely driven by the surgeon's intraoperative assessment of ischemic risk to the flap. Additionally, ischemic complication rates were similar between the two groups, suggesting that VDR may not provide a significant benefit. However, it's possible that ischemic complications were prevented by the use of VDR. A randomized trial is needed to determine the true benefit of VDR.

Sources: (1). Prabhu, S., Llull, R., & Katz, A. (2022). The Language of Implant-based Breast Reconstruction: Can We Do Better? Plast Reconstr Surg Glob Open, 10(8), e4482. https://doi.org/10.1097/GOX.0000000000004482
(2). Ananthakrishnan, P., & Lucas, A. (2008). Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med, 75 Suppl 1, S30-33. https://doi.org/10.3949/ccjm.75.suppl_1.s30 (3). Sullivan, S., Fletcher, D., Isom, C., & Isik, F. (2008). True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg, 122(1), 19-28. https://doi.org/10.1097/PRS.0b013e3181774267

Introduction: The Deep Inferior Epigastric Perforator (DIEP) flap is a widely used approach for breast reconstruction given its incorporation of autologous tissue and minimal donor site morbidity. However, there is debate regarding the use of vasopressors during these procedures, given the concern of vasospasm, thrombosis, or congestion that may compromise flap perfusion. Recent studies have challenged this notion, suggesting that the judicious use of vasopressors may not adversely affect flap outcomes.(1) This study aims to evaluate the impact of intraoperative and perioperative vasopressor use on vascular complications in DIEP flap breast reconstruction and to examine the relationship between vascular anastomosis requirements and vasopressor administration.

Methods: A retrospective review of patients with stage I-III breast cancer (AJCC 8th edition) who underwent DIEP flap breast reconstruction 2023-2024 at a single, quaternary-referral center were included. Primary outcomes were postoperative complications, including wound dehiscence, fat necrosis, partial, and total flap necrosis.

Results: Of 217 patients, 343 DIEP flaps were included, with 41.5% (n=90) and 58.5% (n=127) undergoing unilateral and bilateral DIEP, respectively. The mean BMI was 28.5±3.8. Radiation therapy was administered to 79.3% (n=172) of patients. Vasopressors (phenylephrine, ephedrine, and/or epinephrine) were administered in 34.0% (n=120) of cases, among which 53.4% (n=63) only received vasopressors during induction, 21.2% (n=25) only received vasopressors intraoperatively, and 26.7% (n=32) received vasopressors both at induction and intraoperatively.

Among patients who received vasopressors intraoperatively, 24% (n=6) had wound dehiscence, 28% (n=7) had fat necrosis, and 12% (n=3) had partial flap necrosis. There were no cases of surgical site infection or total flap loss. The median follow-up was 257 days.

Vasopressors administered at induction were associated with the need for additional superficial venous anastomosis (OR=4.69, 95% CI 1.42-15.4, p=0.01). The use of ≥2 vasopressors intraoperatively was associated with venous anastomosis revision (OR=3.70, 95% CI 1.21-11.32, p=0.02). Postoperative blood transfusions, venous anastomosis revision, arterial anastomosis revision, and longer operative time was associated with increased partial flap necrosis (OR=5.91, 95% CI 1.46-23.9, p=0.01; OR=3.58, 95% CI 1.36-9.43, p=0.01; OR=3.33, 95% CI 1.28-8.69, p=0.01; OR 1.31, 95% CI 1.02-1.69, p=0.03, respectively). Importantly, vasopressor use, either administered at induction or intraoperatively, was not associated with an increased risk for postoperative complications.

Conclusion: Vasopressor use, either administered at induction or intraoperatively, was not associated with an increased risk of postoperative complications for patients undergoing DIEP flap breast reconstruction. However, vasopressor use may portend technical challenges, particularly with the venous anastomosis. The judicious use of vasopressors is recommended.

1. Szabo Eltorai A, Huang CC, Lu JT, Ogura A, Caterson SA, Orgill DP. Selective Intraoperative Vasopressor Use Is Not Associated with Increased Risk of DIEP Flap Complications. Plast Reconstr Surg. 2017;140(1):70e-77e. doi:10.1097/PRS.0000000000003444

Background: Nipple preservation with mastectomy improves aesthetic outcome, patient satisfaction, and wellbeing. However, patients with high BMI, comorbidities, and significant breast ptosis have increased risk profiles in breast reconstruction, which historically precluded them from nipple-sparing mastectomy (NSM) and implant-based breast reconstruction (IBBR). The Goldilocks technique, contouring residual mastectomy skin flaps to shape a breast mound, was originally introduced to provide enhanced cosmesis and breast volume in these high-risk patients previously ineligible for IBBR. Recent studies demonstrate modified Goldilocks techniques that repurpose the dermal pedicle to provide autologous NSM or enhanced support for IBBR in high-risk patients. However, there is no study to date that evaluates the safety and efficacy of Nipple-Sparing Goldilocks with IBBR in patients with high BMIs and significant ptosis.

Objective: To characterize the safety of Nipple-Sparing Goldilocks (NSGL) versus Traditional NSM (TNSM) with IBBR in patients with high BMI and breast ptosis.

Methods: A retrospective analysis was conducted on patients undergoing NSGL or TNSM with immediate prepectoral IBBR at the University of Oklahoma Health Sciences Center from January 2023 to April 2024. Exclusion criteria included ADM use and prior breast surgery. Inclusion criteria required minimum 3-month follow-up and complete preoperative measurements (BMI, sternal notch-to-nipple (SNN), nipple-to-inframammary fold (NIMF) and mid-clavicle-to-nipple distance (MCN)). Postoperative complications, characterized by nipple necrosis, wound dehiscence, infection, device exposure and failure, and pocket salvage, were compared using univariate and multivariate data analysis. P < 0.05 determined significance.

Results: A total of 49 patients (84 breasts) were included. Mean follow-up was 10 and 14 months for NSGL (n = 54 breasts) and TNSM (n = 30 breasts), respectively. NSGL had significantly higher BMI (35.5 vs. 25.7 kg/m2, p < 0.0001) and greater ptosis measurements (SNN, MCN, NIMF; all p < 0.0001) than TNSM, while age was similar across groups. There was no significant difference in overall complication rate between NSGL (n = 20) and TNSM (n = 8, p = 0.469). Partial nipple necrosis was significantly higher in NSGL (n = 6) versus TNSM (n = 0, p = 0.038). Full nipple necrosis was clinically higher in NSGL (n = 7) than in TNSM (n = 1), though not statistically significant (p = 0.249). All other measures of complication showed no significant differences (p > 0.05), including multivariate and matched analyses adjusting for confounders.

Conclusion: Despite significantly higher BMI and greater ptosis, Nipple-Sparing Goldilocks showed similar overall complication rates to Traditional NSM with IBBR. Even though the Goldilocks group exhibited a higher incidence of nipple necrosis, the difference in full nipple necrosis was not statistically significant, suggesting larger studies are needed to further assess this risk. Importantly, many of these patients with higher BMI and breast ptosis would traditionally not be considered for a nipple-sparing mastectomy and opted for the risk of nipple necrosis in pursuit of improved aesthetics and satisfaction. These findings suggest nipple-sparing Goldilocks with IBBR is safe in high-risk patients, expanding reconstructive possibilities for those historically excluded from nipple-sparing mastectomy.

Purpose: The use of tranexamic acid (TXA) in reduction mammaplasty is increasing among plastic surgeons. Its efficacy and impact on complications, however, are not yet well understood. Previous reviews analyzing TXA use in breast surgery have included multiple different procedures leading to variable results. This study, however, aims to comprehensively evaluate the impact of TXA on postoperative outcomes in reduction mammaplasty alone.

Methods: A systematic review was conducted according to PRISMA guidelines. Pubmed, MEDLINE, CENTRAL, Scopus, and Web of Science databases were queried to identify studies reporting TXA application in breast surgery. A dual-screener approach was employed to select reduction mammaplasty studies for full-text screening. Primary outcomes assessed were hematoma and seroma; secondary outcomes assessed were surgical site infection (SSI), nipple-areola complex (NAC) necrosis, drain output, drain duration, and thromboembolic events. Data were pooled, and a meta-analysis was performed. Odds ratios (OR) and mean differences were reported via the Mantel-Haenszel and Inverse-Variance methods, respectively.

Results: Seven studies with a total of 1,396 patients were included, with 53.1% of patients (n=741) receiving TXA. Of those receiving TXA, 100% of patients received TXA intraoperatively, and 62.6% of patients (n=464) received both topical and intravenous administration. TXA administration significantly reduced postoperative hematoma formation (OR 0.35; 95% CI [0.20-0.63]; P < 0.001), with 2.3% of patients (n=17) developing hematomas in the TXA group, compared to 7.2% of patients (n=47) in those who did not receive TXA. No statistically significant differences were found in seroma rates, SSI, NAC necrosis, or drain duration. No thromboembolic events were reported in either group.

Conclusion: TXA administration during reduction mammaplasty reduced the incidence of postoperative hematoma formation without impacting postoperative seroma, SSI, NAC necrosis, drain duration, or thromboembolic events.

Purpose: Breast reduction mammaplasty is one of the most commonly performed plastic surgery procedures, and loss of sensation is a common concern among patients. While some evidence suggests that long-term loss of tactile sensation in the nipple-areolar complex (NAC) may not be significant, limited data exists regarding changes in temperature sensation and tactile sensation across all breast regions over time. This study aims to assess longitudinal changes in tactile and temperature sensation following breast reduction.

Methods: Forty-six patients (n = 94 breasts) undergoing reduction mammaplasty with superomedial or superior pedicle and Wise pattern incisions were prospectively followed. Neurosensory testing was completed at 9 breast regions (outer superior, outer medial, outer inferior, outer lateral, inner superior, inner medial, inner inferior, inner lateral, and NAC) using a pressure-specified sensory device to record sensation on a scale of 0 to 100, where higher values indicate worse sensitivity. Temperature detection was assessed with a hot and cold pack at 5 regions (superior, medial, inner, lateral, and NAC). Neurosensory and temperature sensation testing were performed preoperatively and then at 1 month, 3-6 months, and 12 or more months postoperatively. Student t-tests and chi-squared tests were performed to determine differences in tactile and temperature sensation from baseline, respectively.

Results: Preoperatively, the average tactile sensation was 29.4 g/mm² on the breast and 18.4 g/mm² on the NAC. By 1 month postoperatively, tactile sensation had returned to baseline in all regions except for the inner inferior (42.2 g/mm² vs. 31.5 g/mm²), inner lateral (38.1 g/mm² vs. 29.1 g/mm²), and NAC (44.7 g/mm² vs. 18.4 g/mm²) regions (p < 0.05). Tactile sensation had returned to baseline in all breast regions by 3-6 months, except for the NAC (26.9 g/mm² vs. 18.4 g/mm², p < 0.05), which did not return to baseline until 12+ months. Preoperatively, heat sensation was accurately identified 99.4% of the time on the breast and 98.8% on the NAC, while cold sensation was accurately identified 100% of the time on the breast and 97.6% on the NAC. By 1 month postoperatively, hot and cold sensation was significantly worse at the inferior breast (76.3% vs. 98.8% for hot sensation, 63.2% vs. 100% for cold sensation; p < 0.05) and NAC (76.3% vs. 98.8% for hot sensation, 55.3% vs. 97.6% for cold sensation; p < 0.05), while all other breast regions were at baseline. These reductions in temperature sensitivity persisted throughout the follow-up period of 12 or more months (p < 0.05).

Conclusion: These results indicate that sensation is preserved in the medial, superior, and lateral areas of the breast following reduction mammaplasty with superomedial or superior pedicle and Wise pattern incision. Tactile sensation returned to baseline in all regions within 12 months or more, with the NAC taking the longest to recover. While temperature sensation improved over time, it remained diminished in the inferior breast and NAC. This information can be used to guide patient counseling regarding sensory outcomes following breast reduction mammaplasty.

Purpose: Breast reduction mammaplasty is one of the most commonly performed plastic surgery procedures, and loss of sensation is a common concern among patients. While some evidence suggests that long-term loss of tactile sensation in the nipple-areolar complex (NAC) may not be significant, limited data exists regarding changes in temperature sensation and tactile sensation across all breast regions over time. This study aims to assess longitudinal changes in tactile and temperature sensation following breast reduction.

Methods: Forty-six patients (n = 94 breasts) undergoing reduction mammaplasty with superomedial or superior pedicle and Wise pattern incisions were prospectively followed. Neurosensory testing was completed at 9 breast regions (outer superior, outer medial, outer inferior, outer lateral, inner superior, inner medial, inner inferior, inner lateral, and NAC) using a pressure-specified sensory device to record sensation on a scale of 0 to 100, where higher values indicate worse sensitivity. Temperature detection was assessed with a hot and cold pack at 5 regions (superior, medial, inner, lateral, and NAC). Neurosensory and temperature sensation testing were performed preoperatively and then at 1 month, 3-6 months, and 12 or more months postoperatively. Student t-tests and chi-squared tests were performed to determine differences in tactile and temperature sensation from baseline, respectively.

Results: Preoperatively, the average tactile sensation was 29.4 g/mm² on the breast and 18.4 g/mm² on the NAC. By 1 month postoperatively, tactile sensation had returned to baseline in all regions except for the inner inferior (42.2 g/mm² vs. 31.5 g/mm²), inner lateral (38.1 g/mm² vs. 29.1 g/mm²), and NAC (44.7 g/mm² vs. 18.4 g/mm²) regions (p < 0.05). Tactile sensation had returned to baseline in all breast regions by 3-6 months, except for the NAC (26.9 g/mm² vs. 18.4 g/mm², p < 0.05), which did not return to baseline until 12+ months. Preoperatively, heat sensation was accurately identified 99.4% of the time on the breast and 98.8% on the NAC, while cold sensation was accurately identified 100% of the time on the breast and 97.6% on the NAC. By 1 month postoperatively, hot and cold sensation was significantly worse at the inferior breast (76.3% vs. 98.8% for hot sensation, 63.2% vs. 100% for cold sensation; p < 0.05) and NAC (76.3% vs. 98.8% for hot sensation, 55.3% vs. 97.6% for cold sensation; p < 0.05), while all other breast regions were at baseline. These reductions in temperature sensitivity persisted throughout the follow-up period of 12 or more months (p < 0.05).

Conclusion: These results indicate that sensation is preserved in the medial, superior, and lateral areas of the breast following reduction mammaplasty with superomedial or superior pedicle and Wise pattern incision. Tactile sensation returned to baseline in all regions within 12 months or more, with the NAC taking the longest to recover. While temperature sensation improved over time, it remained diminished in the inferior breast and NAC. This information can be used to guide patient counseling regarding sensory outcomes following breast reduction mammaplasty.

PURPOSE Preserving sensation after mastectomy is a key concern for women. This pilot study compares sensory recovery and patient-reported outcomes between patients undergoing single-nerve versus dual-nerve coaptation in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS Patients undergoing mastectomy with DIEP flap reconstruction by a single surgeon were identified. Before 2023, a single nerve coaptation was performed between a thoracoabdominal nerve and the anterior cutaneous branch of T3. Starting in 2024, a second coaptation was added using the lateral branch of T3. Neurosensory testing using the pressure-specified sensory device was conducted across nine breast regions preoperatively and at 3, 6, and 9 months postoperatively. Average sensory recovery was evaluated relative to baseline and compared between the single-neurotized and dual-neurotized groups.

At 6 months postoperatively, the BREAST-Q Reconstruction Module (breast satisfaction, physician satisfaction, psychosocial well-being, sexual well-being, and physical well-being (chest)) and the BREAST-Q Sensation Module (breast symptoms, breast sensation, and sensation-related quality of life (QOL)) were administered. Each domain was rescaled from 1 to 4 on a Likert scale and compared between cohorts using Student's t-test.

RESULTS This study included 29 single-neurotized patients (50 breasts) and 16 dual-neurotized patients (30 breasts). Demographics, comorbidities, and adjunctive oncologic treatments were comparable between groups.

At 3 months postoperatively, the dual-neurotized group demonstrated better sensory recovery compared to the single-neurotized group (54.8% vs. 41.2%), with results approaching statistical significance (p = 0.092). By 6 months, the dual-neurotized group showed significantly superior sensation (70.3% vs. 42.5%, p = 0.002), and this difference remained significant at 9 months (74.8% vs. 47.0%, p = 0.015).

Within the BREAST-Q Reconstruction Module, the two cohorts were comparable in breast satisfaction, physician satisfaction, chest physical well-being, and sexual well-being. However, psychosocial well-being scores were significantly higher in the dual-neurotized cohort (3.24 vs. 2.78, p = 0.041), particularly in questions related to emotional health, self-confidence, feeling feminine, and feeling normal.

Within the BREAST-Q Sensation Module, the dual-neurotized cohort reported significantly higher scores in the breast sensation domain (1.65 vs. 1.13, p = 0.045). However, the breast symptoms and sensation-related QOL domains were comparable between groups.

CONCLUSION This pilot study supports dual-nerve coaptation in DIEP flap breast reconstruction, demonstrating superior objective and subjective sensory recovery compared to single-nerve coaptation. Additionally, psychosocial well-being scores were significantly higher in the dual-neurotized cohort, particularly in areas of emotional health, self-confidence, and overall sense of normalcy.

PURPOSE Preserving sensation after mastectomy is a key concern for women. This pilot study compares sensory recovery and patient-reported outcomes between patients undergoing single-nerve versus dual-nerve coaptation in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS Patients undergoing mastectomy with DIEP flap reconstruction by a single surgeon were identified. Before 2023, a single nerve coaptation was performed between a thoracoabdominal nerve and the anterior cutaneous branch of T3. Starting in 2024, a second coaptation was added using the lateral branch of T3. Neurosensory testing using the pressure-specified sensory device was conducted across nine breast regions preoperatively and at 3, 6, and 9 months postoperatively. Average sensory recovery was evaluated relative to baseline and compared between the single-neurotized and dual-neurotized groups.

At 6 months postoperatively, the BREAST-Q Reconstruction Module (breast satisfaction, physician satisfaction, psychosocial well-being, sexual well-being, and physical well-being (chest)) and the BREAST-Q Sensation Module (breast symptoms, breast sensation, and sensation-related quality of life (QOL)) were administered. Each domain was rescaled from 1 to 4 on a Likert scale and compared between cohorts using Student's t-test.

RESULTS This study included 29 single-neurotized patients (50 breasts) and 16 dual-neurotized patients (30 breasts). Demographics, comorbidities, and adjunctive oncologic treatments were comparable between groups.

At 3 months postoperatively, the dual-neurotized group demonstrated better sensory recovery compared to the single-neurotized group (54.8% vs. 41.2%), with results approaching statistical significance (p = 0.092). By 6 months, the dual-neurotized group showed significantly superior sensation (70.3% vs. 42.5%, p = 0.002), and this difference remained significant at 9 months (74.8% vs. 47.0%, p = 0.015).

Within the BREAST-Q Reconstruction Module, the two cohorts were comparable in breast satisfaction, physician satisfaction, chest physical well-being, and sexual well-being. However, psychosocial well-being scores were significantly higher in the dual-neurotized cohort (3.24 vs. 2.78, p = 0.041), particularly in questions related to emotional health, self-confidence, feeling feminine, and feeling normal.

Within the BREAST-Q Sensation Module, the dual-neurotized cohort reported significantly higher scores in the breast sensation domain (1.65 vs. 1.13, p = 0.045). However, the breast symptoms and sensation-related QOL domains were comparable between groups.

CONCLUSION This pilot study supports dual-nerve coaptation in DIEP flap breast reconstruction, demonstrating superior objective and subjective sensory recovery compared to single-nerve coaptation. Additionally, psychosocial well-being scores were significantly higher in the dual-neurotized cohort, particularly in areas of emotional health, self-confidence, and overall sense of normalcy.