Scientific Abstract Presentations: Breast Session 5 Friday, October 10 Fri, Oct 10 5:00-6:00 p.m. CDT

Introduction: Implant-based breast reconstruction (IBBR) remains the most common form of post-mastectomy breast reconstruction, with evolving techniques tailored to individual body types (1). Large, ptotic breasts present unique surgical challenges (2). The skin-reducing mastectomy (SRM) offers favorable aesthetic outcomes for ptotic breasts, yet its impact on postoperative complications remains debated. Some studies suggest higher risks of hematoma and wound dehiscence, while others argue it may be a safer alternative than traditional mastectomy incisions (1, 2). Few studies have compared revision rates. This study aims to examine the rates of postoperative outcomes and revisions between SRM and non-SRM (NSRM) patients.

Methods: A retrospective review was conducted on patients with grade II or III ptosis who underwent IBBR between 2018 and 2024 at two medical institutions. A total of 192 patients (342 breasts) met inclusion criteria. Demographics, medical history, operative details, postoperative complications, and revision rates were analyzed. Major complications were defined as those requiring reoperation.

Results: Patients were stratified into SRM (35 patients, 67 breasts) and NSRM (157 patients, 275 breasts) groups. Baseline characteristics were similar except for BMI, mental health conditions, and ptosis grade. SRM breasts had 2.8 times higher odds of major complications compared to NSRM breasts (p=0.014, CI 1.13–6.66). While overall and minor complication rates were not significantly different between groups, SRM breasts had 3.38 times higher odds of infection (p=0.010, CI 1.20–9.23) and 5.14 times higher odds of skin necrosis (p=0.002, CI 1.68–16.04). No significant differences were found in rates of wound dehiscence, seroma, hematoma, implant exposure, or implant rupture. Numbers of revision surgery differed significantly between groups (0.37 SRM vs. 0.74 NSRM, p=0.038), though the percentage of patients undergoing revision, fat grafting, scar revision, capsulorrhaphy, or capsulectomy was comparable. After adjusting for significant covariables, SRM breasts remained 2.63 times more likely to experience major complications (p=0.036, CI 1.03–6.38), while SRM patients had 2.5 times lower odds of undergoing revision surgery (p=0.020, CI 0.17–0.84).

Conclusion: SRM is associated with a higher risk of major complications, infections, and skin necrosis compared to NSRM but a lower overall number of revision procedures. However, the likelihood of undergoing revision surgery remains similar between groups. These findings highlight the importance of careful patient selection and surgical planning when considering SRM in IBBR.

References: 1. Chemakin, K., Ricci, J. A., Benacquista, T., Draper, L., & Weichman, K. (2024). Mastectomy Incision Choice in Ptotic Patients Undergoing Immediate Implant-Based Reconstruction. Annals of Plastic Surgery, 93(2), 163–171. https://doi.org/10.1097/SAP.0000000000003969 2. Roostaeian, J., Pavone, L., da Lio, A., Lipa, J., Festekjian, J., & Crisera, C. (2011). Immediate placement of implants in breast reconstruction: Patient selection and outcomes. Plastic and Reconstructive Surgery, 127(4). https://doi.org/10.1097/PRS.0b013e318208d0ea

PURPOSE The BREAST-Q Sensation Module, developed in 2020, standardizes patient-reported measures of breast sensation and its impact on quality of life (QOL). This study utilizes the module to compare long-term patient-reported outcomes among breast reconstruction patients with the least, moderate, and most sensate breasts.

METHODS Patients who underwent mastectomy with immediate reconstruction by a single surgeon were identified. Postoperative neurosensory testing was performed using a pressure-specified sensory device, with scores ranging from 0 to 100 g/mm², where higher scores indicate worse sensation. At each testing session, patients also completed the BREAST-Q Sensation Module, which assesses three domains: (1) subjective breast sensation, (2) adverse breast symptoms, and (3) sensation-related QOL.

Only patients who underwent neurosensory testing more than 12 months after surgery were included. They were stratified into three cohorts based on objective sensory scores: most sensate (≤ 50 g/mm²), moderately sensate (> 50 g/mm² and < 75 g/mm²), and least sensate (≥ 75 g/mm²). BREAST-Q survey scores were then compared among the three groups using independent t-tests with Bonferroni correction for multiple comparisons.

RESULTS A total of 47 patients (20 alloplastic, 17 deep inferior epigastric perforator (DIEP) flap) were included, with 13 classified as least sensate, 12 as moderately sensate, and 12 as most sensate. The groups were comparable in demographics, comorbidities, reconstruction type distribution, and time to survey completion (median: 36 months; range: 12–60 months).

Subjective patient-reported sensation scores from the BREAST-Q aligned with objective sensory measurements, with the most sensate group reporting the highest subjective sensation scores (2.16 vs. 1.52 vs. 1.21, p < 0.001). Adverse breast symptoms-including stinging, throbbing, burning, aching, and spasms-were statistically similar across groups but were marginally elevated in the moderately sensate cohort.

When assessing the impact of breast sensation on QOL, the most sensate group reported the highest QOL scores, followed by the least sensate group. Notably, the moderately sensate group exhibited the lowest sensation-related QOL scores, with significant reductions in self-confidence, body perception, clothing choices, bra comfort, and sexual life compared to the most sensate group (p < 0.01). No significant differences in QOL scores were observed between the most and least sensate groups.

CONCLUSION
Our findings suggest that patients with moderate breast sensation report the lowest sensation-related QOL. One possible explanation is that patients with moderate sensation may experience heightened awareness of their sensory deficits, leading to greater dissatisfaction. Unlike those in the least sensate group, who may have adapted to their lack of sensation, or those in the most sensate group, who experience near-normal sensory function, the moderately sensate group may exist in a frustrating intermediate state-able to perceive sensation, but with noticeable impairments. Further research is needed to explore the psychological mechanisms underlying this trend and whether targeted patient counseling could mitigate its impact.

PURPOSE The BREAST-Q Sensation Module, developed in 2020, standardizes patient-reported measures of breast sensation and its impact on quality of life (QOL). This study utilizes the module to compare long-term patient-reported outcomes among breast reconstruction patients with the least, moderate, and most sensate breasts.

METHODS Patients who underwent mastectomy with immediate reconstruction by a single surgeon were identified. Postoperative neurosensory testing was performed using a pressure-specified sensory device, with scores ranging from 0 to 100 g/mm², where higher scores indicate worse sensation. At each testing session, patients also completed the BREAST-Q Sensation Module, which assesses three domains: (1) subjective breast sensation, (2) adverse breast symptoms, and (3) sensation-related QOL.

Only patients who underwent neurosensory testing more than 12 months after surgery were included. They were stratified into three cohorts based on objective sensory scores: most sensate (≤ 50 g/mm²), moderately sensate (> 50 g/mm² and < 75 g/mm²), and least sensate (≥ 75 g/mm²). BREAST-Q survey scores were then compared among the three groups using independent t-tests with Bonferroni correction for multiple comparisons.

RESULTS A total of 47 patients (20 alloplastic, 17 deep inferior epigastric perforator (DIEP) flap) were included, with 13 classified as least sensate, 12 as moderately sensate, and 12 as most sensate. The groups were comparable in demographics, comorbidities, reconstruction type distribution, and time to survey completion (median: 36 months; range: 12–60 months).

Subjective patient-reported sensation scores from the BREAST-Q aligned with objective sensory measurements, with the most sensate group reporting the highest subjective sensation scores (2.16 vs. 1.52 vs. 1.21, p < 0.001). Adverse breast symptoms-including stinging, throbbing, burning, aching, and spasms-were statistically similar across groups but were marginally elevated in the moderately sensate cohort.

When assessing the impact of breast sensation on QOL, the most sensate group reported the highest QOL scores, followed by the least sensate group. Notably, the moderately sensate group exhibited the lowest sensation-related QOL scores, with significant reductions in self-confidence, body perception, clothing choices, bra comfort, and sexual life compared to the most sensate group (p < 0.01). No significant differences in QOL scores were observed between the most and least sensate groups.

CONCLUSION
Our findings suggest that patients with moderate breast sensation report the lowest sensation-related QOL. One possible explanation is that patients with moderate sensation may experience heightened awareness of their sensory deficits, leading to greater dissatisfaction. Unlike those in the least sensate group, who may have adapted to their lack of sensation, or those in the most sensate group, who experience near-normal sensory function, the moderately sensate group may exist in a frustrating intermediate state-able to perceive sensation, but with noticeable impairments. Further research is needed to explore the psychological mechanisms underlying this trend and whether targeted patient counseling could mitigate its impact.

Purpose: Nicotine dependence is known to cause impaired wound healing and increase risk of surgical complications. This study evaluates the impact of nicotine dependence on postoperative outcomes in patients undergoing breast reconstruction.

Methods: A retrospective cohort study was conducted using data from the TriNetX global health research network. Patients undergoing breast reconstruction (all implant based and free flap) between January 2000 and February 2023 were categorized into two cohorts: those with nicotine dependence documented within 6 months before surgery (n = 9,472) and those without nicotine use (n = 54,061). Primary outcomes included fat necrosis, skin flap necrosis, dehiscence, infection, seroma formation, hematoma formation, implant loss, flap death/loss, reoperation, readmission, and capsular contracture.

Result: Propensity score matching was performed, resulting in balanced cohorts of 9,402 patients each. The nicotine dependence cohort had a higher incidence of seroma formation (3.6% vs. 3.1%, p = 0.042), flap death/loss (1.8% vs 1.3%, p = 0.004), fat necrosis (5.6% vs. 4.2%, p < 0.001), implant loss (1.4% vs. 0.9%, p = 0.001), readmission (18.2% vs 14.2%, p < 0.001), and capsular contracture (4.3% vs 3.3%, p < 0.001). There was no statistically significant difference between the two cohorts with regard to infection (0.2% vs. 0.1%, p = 0.094) and hematoma formation (1.6% vs 1.3%, p = 0.114).

Conclusion: Nicotine dependence increases the risk of many surgical complications in breast reconstruction, especially seroma formation, flap loss, fat necrosis, implant loss, readmission, and capsular contracture. These results emphasize the need for smoking and nicotine cessation prior to breast reconstruction.

Purpose: Nicotine dependence is known to cause impaired wound healing and increase risk of surgical complications. This study evaluates the impact of nicotine dependence on postoperative outcomes in patients undergoing breast reconstruction.

Methods: A retrospective cohort study was conducted using data from the TriNetX global health research network. Patients undergoing breast reconstruction (all implant based and free flap) between January 2000 and February 2023 were categorized into two cohorts: those with nicotine dependence documented within 6 months before surgery (n = 9,472) and those without nicotine use (n = 54,061). Primary outcomes included fat necrosis, skin flap necrosis, dehiscence, infection, seroma formation, hematoma formation, implant loss, flap death/loss, reoperation, readmission, and capsular contracture.

Result: Propensity score matching was performed, resulting in balanced cohorts of 9,402 patients each. The nicotine dependence cohort had a higher incidence of seroma formation (3.6% vs. 3.1%, p = 0.042), flap death/loss (1.8% vs 1.3%, p = 0.004), fat necrosis (5.6% vs. 4.2%, p < 0.001), implant loss (1.4% vs. 0.9%, p = 0.001), readmission (18.2% vs 14.2%, p < 0.001), and capsular contracture (4.3% vs 3.3%, p < 0.001). There was no statistically significant difference between the two cohorts with regard to infection (0.2% vs. 0.1%, p = 0.094) and hematoma formation (1.6% vs 1.3%, p = 0.114).

Conclusion: Nicotine dependence increases the risk of many surgical complications in breast reconstruction, especially seroma formation, flap loss, fat necrosis, implant loss, readmission, and capsular contracture. These results emphasize the need for smoking and nicotine cessation prior to breast reconstruction.

Purpose: Nicotine dependence is known to cause impaired wound healing and increase risk of surgical complications. This study evaluates the impact of nicotine dependence on postoperative outcomes in patients undergoing breast reconstruction.

Methods: A retrospective cohort study was conducted using data from the TriNetX global health research network. Patients undergoing breast reconstruction (all implant based and free flap) between January 2000 and February 2023 were categorized into two cohorts: those with nicotine dependence documented within 6 months before surgery (n = 9,472) and those without nicotine use (n = 54,061). Primary outcomes included fat necrosis, skin flap necrosis, dehiscence, infection, seroma formation, hematoma formation, implant loss, flap death/loss, reoperation, readmission, and capsular contracture.

Result: Propensity score matching was performed, resulting in balanced cohorts of 9,402 patients each. The nicotine dependence cohort had a higher incidence of seroma formation (3.6% vs. 3.1%, p = 0.042), flap death/loss (1.8% vs 1.3%, p = 0.004), fat necrosis (5.6% vs. 4.2%, p < 0.001), implant loss (1.4% vs. 0.9%, p = 0.001), readmission (18.2% vs 14.2%, p < 0.001), and capsular contracture (4.3% vs 3.3%, p < 0.001). There was no statistically significant difference between the two cohorts with regard to infection (0.2% vs. 0.1%, p = 0.094) and hematoma formation (1.6% vs 1.3%, p = 0.114).

Conclusion: Nicotine dependence increases the risk of many surgical complications in breast reconstruction, especially seroma formation, flap loss, fat necrosis, implant loss, readmission, and capsular contracture. These results emphasize the need for smoking and nicotine cessation prior to breast reconstruction.

Introduction/Purpose: Autologous breast reconstruction with DIEP flap places strong emphasis on aesthetic outcomes of the breast, which often comes at the expense of a sub-optimal donor site aesthetic result, especially regarding the location of the abdominal scar and abdominal contouring. The "golden ratio" for umbilicoplasty of 1.6 between xiphoid-umbilicus and umbilicus-lower abdominal crease sets an aesthetic goal for placement of the lower abdominal scar within the lower abdominal crease. The purpose of this study was to propose an increased attention to the abdominal donor site in DIEP flap-based breast reconstruction through aesthetic modifications.

Methods: We introduce an "aesthetic DIEP" reconstruction with a low abdominal incision, bilateral corsetplasty, diastasis repair, ideal umbilicus placement, and second-stage aesthetically-minded abdominal lipoaspiration. The "golden ratio" for umbilicoplasty of 1.6 between xiphoid-umbilicus and umbilicus-lower abdominal crease was used to set placement of the lower abdominal scar within the lower abdominal crease and define umbilicus placement. Corsetplasty and diastasis repair were performed based on laxity along the semilunar lines and linea alba.

Results: Of 107 patients with 189 DIEP flaps by the senior author from 2021-2024, 35 patients underwent low-incision DIEP flap reconstruction. Of these, 18 patients underwent bilateral corsetplasty in combination with diastasis repair. At the second stage, 24 of 26 patients underwent fat grafting with aesthetically enhancing abdominal lipoaspiration. The average ratio of the xiphoid margin-umbilicus to umbilicus-lower incision distance was 1.63 (average umbilicus-lower incision distance of 8.67 cm ± 1.25). Operative time and complications were not significantly different compared to patients with traditional DIEP reconstruction.

Conclusions: Our low abdominal scar allows for better concealment under clothing and reflects the lower abdominal crease in the aforementioned "golden ratio" for umbilicus placement. Enhancing DIEP reconstruction with a low abdominal incision, corsetplasty, and second-stage aesthetically-targeted lipoaspiration yields an improved donor site aesthetic, while maintaining excellent functional outcomes.

Purpose

CT angiography (CTA) is commonly used to identify perforators for deep inferior epigastric perforator (DIEP) flap harvest, resulting in an average reduction of 33.9 minutes for flap dissection (1). A key challenge in utilizing preoperative CTA data is the surgeon's ability to accurately translate perforator locations and vessel trajectories onto the patient during surgery. This study investigates the application of Augmented Reality (AR) to enhance the use of preoperative imaging, with the goal of improving DIEP flap planning and harvest precision.

Methods

Software was developed for the Apple Vision Pro to support AR integration in DIEP flap reconstruction. A sterile 3D-printed optical tracker was introduced to enable accurate and rapid registration. The accuracy of segmentation, registration, and projection was first evaluated using a phantom model to determine the reprojection error. AR-projected points were manually traced on the phantom surface. The coordinates of the AR-projected and manually traced points were recorded relative to a predefined origin in the physical space, with x and y coordinates collected for each point. The reprojection error was quantified as the average displacement between the AR points and their corresponding manually traced counterparts. With institutional ethics approval, patients undergoing DIEP flap reconstruction consented to AR use in this single-surgeon feasibility trial. Segmented anatomy visualized in AR included abdominal soft tissue layers (skin, subcutaneous tissue, fascia, rectus muscle), the deep inferior epigastric artery, perforators, and their intramuscular course. Preoperatively and intraoperatively, the surgeon manipulated the AR visualizations to assess vessel trajectories and calibers, aiding in perforator selection and flap design. Additionally, the integrated Picture Archiving and Communication System (PACS) enabled imaging to be reviewed in AR while maintaining sterility in the operating room, using hand and eye tracking as input methods.

Results

The average reprojection error in the phantom model was 2.08 mm. Three patients underwent AR-assisted DIEP flap reconstruction. Automatic registration with the optical tracker was achieved in an average of 7 seconds (n=3), with a reprojection error of less than 1 cm. Further manual refinement improved accuracy to approximately 2 mm, requiring an average of 72 seconds (n=3). Intraoperatively, accurate registration was confirmed between the AR visualizations and the real patient-specific anatomy following pedicle dissection. The use of AR delineated vascular anatomy in relation to the rectus muscle, fascia, and subcutaneous tissue. AR enabled real-time visualization and interaction with CTA images and segmented anatomy, enhancing perforator selection, fascial incision planning, and intramuscular pedicle dissection.

Conclusion

AR enables accurate translation of preoperative imaging for DIEP flap planning and intraoperative guidance. Based on this feasibility study, a randomized controlled trial is planned to evaluate its impact on operative time, surgical safety, and decision-making.

(1) Colakoglu S, Tebockhorst S, Freedman J, et al. CT angiography prior to DIEP flap breast reconstruction: a randomized controlled trial. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2022;75(1):45-51. doi:10.1016/j.bjps.2021.05.050

PURPOSE: Post-mastectomy radiotherapy in alloplastic breast reconstruction has been linked to capsular contracture rates of up to 40%, increased risk of complications, and poor outcomes (1, 2). There is strong clinical association between radiation and capsular fibrosis(3, 4). The underlying mechanism, specifically whether the radiated tissues or the radiated capsule contribute to peri-prosthetic fibrosis, remains poorly understood. To better characterize radiation-induced capsular fibrosis, we investigated whether capsules from alloplastic breast reconstruction patients with pre-mastectomy radiation differ from the capsules of patients with post-mastectomy radiation by comparing the inflammatory and fibrotic cellular infiltrates.

METHODS: Capsule tissue was collected from pre-mastectomy (N=10) and post-mastectomy (N=10) radiated patients undergoing revision surgery. Experimental groups were matched based on demographic variables. Capsular thickness was assessed using Masson Trichrome. Capsular cellular populations were measured with immunohistochemistry (total macrophages, M1 pro-inflammatory macrophages, M2 wound-healing macrophages, CD3+ total T-Cells, CD4+ helper T-cells, fibroblasts, and myofibroblasts).

RESULTS: The demographics of the two groups were statistically similar. Pre-mastectomy radiation capsules were thicker (p=0.08) and contained an increased infiltrate of M2 wound-healing macrophages (p=0.07), CD3+ total-T cells (p=0.15), myofibroblasts (p=0.6) and fibroblasts (p=0.0009). In comparison, post-mastectomy radiation capsules displayed increased total macrophages (p=0.53), M1 pro-inflammatory macrophages (p=0.66) and CD4+ T cells (p=0.56).

CONCLUSIONS: Our results suggest that the cellular response in capsular tissue varies based on the timing of radiation therapy. Pre-mastectomy radiation capsules exhibit an anti-inflammatory, wound-healing phenotype, potentially mediating the deposition of fibroblasts and myofibroblasts, leading to thicker capsules. Post-mastectomy radiation induced a pro-inflammatory phenotype with increased CD4+ T cell infiltration. Expanding our understanding of these differences could determine the mechanisms underlying radiation-induced capsular contracture and provide insight into ways of minimizing its impact on patients.

REFERENCES: 1. Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res. 2017;218:108-16. 2. Magill LJ, Robertson FP, Jell G, Mosahebi A, Keshtgar M. Determining the outcomes of post-mastectomy radiation therapy delivered to the definitive implant in patients undergoing one- and two-stage implant-based breast reconstruction: A systematic review and meta-analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2017;70(10):1329-35. 3. Lipa JE, Qiu W, Huang N, Alman BA, Pang CY. Pathogenesis of radiation-induced capsular contracture in tissue expander and implant breast reconstruction. Plast Reconstr Surg. 2010;125(2):437-45. 4. Hammond JB, Kosiorek HE, Cronin PA, Rebecca AM, Casey WJ, III, Wong WW, et al. Capsular contracture in the modern era: A multidisciplinary look at the incidence and risk factors after mastectomy and implant-based breast reconstruction. The American Journal of Surgery. 2021;221(5):1005-10.

Purpose:

Central lumpectomy is growing in popularity as an alternative to mastectomy in patients with subareolar breast cancer and/or involvement of the nipple-areolar complex (NAC). Traditionally, these patients have been excluded from consideration of breast conservation therapy (BCT) due to concerns of suboptimal aesthetic outcomes, leaving mastectomy as the only remaining option.1 However, with advancements in oncoplastic breast surgery, including techniques like adjacent tissue transfer and oncoplastic tissue rearrangement, cosmetic results and breast symmetry have greatly improved, making BCT a feasible option for a broader range of patients. This case series reviews oncoplastic reconstruction of central lumpectomy defects among patients with a range of breast phenotypes and tumor characteristics.

Methods:

Patients who underwent central lumpectomy with subsequent reconstruction from 2021 to 2024 were retrospectively identified and queried for demographic data, disease characteristics, adjuvant therapy, reconstructive techniques, and postoperative outcomes.

Results:

Nine patients who underwent central lumpectomy with total or subtotal NAC resection followed by immediate reconstruction were identified. The mean age of the patients was 56.2 years, and the mean BMI was 31.97 kg/m2 (range: 20.32 to 39.41). Preoperative breast cup sizes ranged from B to EE. The mean tumor size was 21.6 mm (± 9.1), with a mean tumor weight of 51.8 g (± 25.8). Seven breasts were reconstructed using an oncoplastic reduction mammoplasty approach, while two were reconstructed with a lateral intercostal artery perforator (LICAP) flap. Circular skin paddles were included in six reconstructions and immediate nipple reconstructions were performed in two patients. Six patients underwent contralateral surgery for symmetry at the time of their reconstruction. Minor wound healing complications were reported in five patients (55%); of these, two required a delayed start to radiation, one required readmission, and two underwent revision surgery at post-operative times points of two weeks and 17 months. Mean follow-up was 276 days (range: 53 to 776).

Conclusions:

Concerns regarding feasibility and aesthetic outcomes following central lumpectomy reconstruction have historically limited the number of patients considered candidates for breast conservation therapy. Our case series demonstrates successful central lumpectomy reconstructions with favorable outcomes in patients across a broad range of tumor size and body habitus. Aesthetic results can be optimized through individualized preoperative planning based on the patient's breast shape and size. These findings support expanding access of BCT to include patients undergoing central lumpectomy with NAC resection.

References 1. Bertozzi N, Pesce M, Santi PL, Raposio E. Oncoplastic breast surgery: comprehensive review. Eur Rev Med Pharmacol Sci. 2017;21(11):2572-2585.

Background: Deep inferior epigastric perforator (DIEP) flaps are an increasingly common option for breast reconstruction patients. However, this procedure also poses a relatively high risk for venous thromboembolism (VTE) in plastic surgery patients. While individual patient risk factors for coagulation must be considered to tailor postoperative prevention, it remains challenging to predict which patients will develop VTE. This study evaluates the effectiveness of a standardized prophylactic regimen for VTE prevention in DIEP patients, integrated with Enhanced Recovery After Surgery (ERAS) protocols. Methods: A prophylactic protocol was implemented for DIEP patients at a single institution starting in October 2021. Preoperative measures included patient education and subcutaneous heparin administration. Intraoperatively, shorter fascial incisions and pedicle lengths minimized operative time, while pain was managed with transversus abdominis plane (TAP) blocks and incisional infiltration analgesia. Postoperatively, patients were discharged on day one with two weeks of enoxaparin sodium (Lovenox), lower extremity sequential compression devices (SCDs), compressive garments, and physical therapy beginning the day after surgery to encourage early ambulation. This regimen was universally applied, regardless of individual VTE risk factors. A retrospective review of DIEP flap patients operated on between October 2021 and July 2024 assessed posteropative deep vein thrombosis (DVT) or pulmonary embolism (PE) as the primary outcome. Results: Among 189 DIEP flaps in 110 patients, one patient developed an upper extremity DVT 120 days after initial DIEP reconstruction and one day after bilateral revision surgery. No other VTEs were reported during the six-month average follow-up period. This protocol did not increase bleeding complications, emergency room visits, or readmissions. Conclusion: This standardized VTE prophylactic protocol effectively reduced the risk of DVT and PE in DIEP flap breast reconstruction patients without increasing bleeding or other complications. It offers a safe, adaptable approach suitable for ERAS protocols, warranting further prospective evaluation.

Introduction The need for post mastectomy radiation therapy (PMRT) is a foundational component of multimodal breast cancer treatment for locally advanced disease. However, it can delay the reconstruction process, often leads to unfavorable cosmetic outcomes, and has high complication rates. In order to minimize postoperative complications, patients undergoing PMRT have been traditionally offered delayed, and more recently, delayed immediate autologous breast reconstruction 6-9 months after radiation. However, this process has physical and mental health implications for the patient who has to live without a breast for a substantial period, often endures painful radiation induced contractures, and a poorer aesthetic outcome due to the loss of the breast skin envelope. Similarly, delayed immediate reconstruction in the setting of PMRT is commonly associated with expander related complications.

Recently, a study performed at MD Anderson Cancer Center showed success with the delivery of neoadjuvant radiation therapy (NRT) therapy 2-5 weeks prior to mastectomy and immediate autologous breast reconstruction, challenging the classic teaching.1

Applying these principles in the adjuvant setting, this study evaluated the feasibility and safety of performing autologous breast reconstruction within a 2–4-week interval after PMRT.

Methods Between April to November 2024, patients who underwent PMRT followed by DIEP flap breast reconstruction within 3 weeks after PMRT were retrospectively identified and analyzed. The primary outcome was complete autologous flap loss. Demographic, treatment, and outcomes data were collected.

Results Three patients were identified. All patients received 50 Gy in 25 fractions to the chest wall and regional nodes for 5 weeks following an average of 60.3 days (range: 53-73 days) after mastectomy. All patients underwent DIEP flap breast reconstruction at an average of 19.7 days (range: 17-21 days) after PMRT. The patients had no intra or postoperative complications, including no flap related issues/loss, skin or fat necrosis, infection, seroma, or hematoma. Notably, intraoperatively the patients' recipient internal mammary vessels were found to be soft and pliable clinically indistinguishable from virgin vessels without any evidence of radiation damage. Both the surgeon and patient were satisfied with their results, with an average postoperative BREAST-Q breast satisfaction score of 87, psychosocial well-being score of 73.5, and sexual well-being score of 62.5 (rated on a scale from 0 (worst) to 100 (best)).

Conclusion Short interval free autologous breast reconstruction (SIBT) after PMRT was successful and safe. This strategy streamlines the reconstructive process, minimizes patient discomfort, and expedites the overall reconstruction timeline for breast cancer patients undergoing adjuvant radiation without exposing the flap to any untoward radiation induced sequela. A larger randomized control study to better determine the safety and efficacy of SIBT is currently underway.

References: 1. Hoffman KE, Smith BD, Singh P, et al. Prospective Clinical Trial of Premastectomy Radiotherapy Followed by Immediate Breast Reconstruction for Operable Breast Cancer. International Journal of Radiation Oncology, Biology, Physics. 2023;117(2):e179-e180. doi:10.1016/j.ijrobp.2023.06.1030

Introduction:

For many patients, presence of a nipple on a reconstructed breast defines completion of breast restoration. Increased patient satisfaction following nipple preservation/reconstruction has been reported regarding symmetry, aesthetics, shape, texture, and perceived sexual attractiveness. These findings elucidate both psychological and physical benefits to patients provided by the presence of a nipple following breast reconstruction

Free nipple grafting(FNG) has been long reported as a viable alternative for aesthetic results and patient satisfaction in the setting of reduction mammaplasty in severe macromastia. Though FNG has been associated with drawbacks such as nipple depigmentation, projection loss, loss of sensation, and nipple viability, the FNG method has the potential to provide immense aesthetic satisfaction to patients with large, ptotic breasts. This study demonstrates that the same concept as FNG used for reduction mammaplasty can be applied to autologous reconstruction following mastectomy in patients that do not qualify for nipple sparing mastectomy. This study reports the use of FNG at time of mastectomy, in conjunction with autologous breast reconstruction to provide a "nipple-sparing" result.

Methods:

A retrospective chart review was performed at two institutions for patients who underwent immediate autologous breast reconstruction with simultaneous FNG by the senior author(KMP). Patient information collected included age, gender, BMI, indication for procedure and follow-up time. Recorded outcomes included nipple survival, nipple depigmentation, nipple revision and post-surgical complications. Statistical analysis was completed using IBM SPSS 24.

Results:

A total of 44 patients who underwent a total of 72 nipple grafts were performed. The population mean age was 53.6 years, mean BMI was 28.9 and mean follow-up was 366 months. 43 patients(69 breasts) underwent autologous reconstruction using the deep inferior epigastric perforator(DIEP) flap(15 unilateral, 54 bilateral). 1 patient underwent unilateral TRAM flap, and 1 patient underwent bilateral pedicled latissimus dorsi flaps.

A total of 38 nipple grafts were performed on the right breast, including 11 cancerous breasts. 34 nipple grafts were performed on the left breast, of which 21 were on the cancerous side. Average mastectomy breast weight was 862g for the right breast and 1022g for the left breast. 12 patients underwent neoadjuvant chemo, 2 underwent neoadjuvant radiation, 12 patients underwent adjuvant chemo, and 5 patients underwent adjuvant radiation.

100% of nipple grafts survived, with no grafts demonstrating nipple necrosis and or flap loss. 14 patients(38.1%) had minor postoperative complications, including: 7 patients with wound dehiscence, 4 patients(4 nipples) demonstrated nipple depigmentation, and 3 patients requested further cosmetic surgical intervention/revision.

Conclusion:

For patients who are not candidates for NSM, FNG offers a viable alternative in conjunction with reconstruction. This technique preserves the 3-dimensionality of the nipple areola complex as well as some native dermal and epidermal architecture, leading to a more natural appearance compared to nipple reconstruction with or without tattooing. Based on the results of this study, mastectomy with FNG and autologous reconstruction allows for favorable aesthetic outcomes with minimal postoperative complications or nipple loss. While limitations of FNG persist, it remains a safe and cosmetically beneficial option for patients with limited native nipple preservation choices.